St. Andrew's Episcopal Church
2011 Summer Youth Experience:
Boat Science!
Tuesday, July 5 - Friday, July 29
9am - 2pm
Application
Science teacher, sailor and boat-building enthusiast Jeff Michals-Brown will lead kids in boat-related experiments and modeling, and the kids will help to build a real boat.
The program is open to all middle school youth near St. Andrew's Episcopal Church, New Bedford. Participants will need to bring a lunch and two snacks each day.
Participants will be chosen from those who have returned completed registration form and submitted a school/camp health form. Space is limited! Applications are past due.
Child's name: ____________________________________________
Age: __ Date of Birth: _____ Name of school (2010-11): _______________________
Street Address: _________________________________________
Home phone: __________________________________
Parent's names and cell phone numbers--
parent 1: _____________________________ cell: ____________________
parent 2: _____________________________ cell: ____________________
Emergency Contacts other than parent
1 name: _________________________________ relationship: _________________
phone: _____________________________ cell: ___________________________
2 name: _________________________________ relationship: _________________
phone: _____________________________ cell: ___________________________
At dismissal time (2pm), my child will-
o go home on his/her own
o be picked up by a parent
o other (explain): ______________________________________________________
Please describe any special needs your child has: ________________________________
__________________________________________________________________________________________________________________________________________________
Note: a parent picking up his/her child may be asked for photo id. This is for your own child's safety. In the event you want a person not listed on this form to be able to do a pick-up, you will need to send a note saying so when your child comes to the program.
Safety: During this program your child will be helping to build a small boat. In the process, you child will be using tools that may include (but are not limited to) hand saws, electric drills and edge tools. In the event your child displays unsafe behavior, he or she may be sent home at the judgment of staff. Although your child will be supervised and ordinary precautions taken, cuts, scrapes and splinters are not unknown. Minor injuries will be treated by staff. However, we need the following permissions in the event of a serious injury:
CONSENT FOR EMERGENCY MEDICAL TREATMENT
I do hereby give authority to the St. Andrews summer staff to obtain necessary medical treatment for my child with the understanding that the family will be notified as soon as possible. No one will be permitted to attend the camp program without a complete school/camp form on file. All medical forms are due before your child starts camp.
__________________________ ____________________________
Parent’s Name (Print) Parent’s Signature
__________________________
Date
EMERGENCY RELEASE
If I cannot be reached (in the event of an emergency) I hereby authorize the physician at the local hospital facility to provide emergency care deemed necessary for my child/children.
________________________ ____________________________
Parent’s Name (Print) Parent’s Signature
__________________________
Date
FIRST AID
In the event of an emergency and I cannot be reached I hereby authorize the St. Andrews summer staff to conduct or provide any first aid necessary for my child/children.
________________________ ____________________________
Parent’s Name (Print) Parent’s Signature
__________________________
Date
