RECA Children's Chinese Culture Camp Enrollment Form
Please use a separate form for each student enrolling
Please make checks payable to RECA CHINESE SCHOOL and mail to:
RECA Children's Culture Camp, PO Box 7854, Santa Rosa, CA 95407
For additional information:
Judy Cheung: (707) 528-0912 (English)
Nancy Wang: (707) 576-0533 (English or Mandarin)
Name of student: ________________________________________________________
Age: ______ Birthdate: __________________
City___________________________________ Zip: _________________
Home Telephone: __________________________________
Alternate phone _________________________________________
Parent's or guardian's name: _________________________________________________________________________
WAIVER OF LIABILITY
In consideration of the acceptance of my application for the REDWOOD EMPIRE CHINESE ASSOCIATION Chinese School, I do hereby for myself, my heirs, executors and administrators, waive, release and forever discharge any and all rights and claims for damages which I may have or which may hereafter accrue to me against the RECA Chinese School or their responsible officers, directors, agents, representatives, successors, and/or assigns for any and all damages which may be sustained and suffered by me in connection with my said / or arising out of my traveling to, participating in and returning from said activities.
Parent or guardian signature: ______________________________________________________________________________
Required for students under age 18
Cost of the two week camp is $250.00 per child [$20/child per hour or portion of hour after 3:30] . Parents are welcome to participate as teacher assistants. Camp will be held July 15-19, 9:00-3:00, M-F. Location is RECA Center, 3455 Sebastopol Road, Santa Rosa, CA.
EMERGENCY INSTRUCTIONS (Required for children under 18)
Parent/ Guardian: ______________________________________________________________________
Telephone if different from above: _____________________________________________________
Alternate name to call in emergency: ____________________________________________________
Does this student have any physical ailments (such as diabetes, allergies, asthma, etc.) or does this student take medication during class time?
If yes, describe _____________________________________________________________________________________
Date of last tetanus immunization: ______________________
Doctor: _____________________________________________Phone: _____________________________
MEDICAL TREATMENT AUTHORIZATION (Required for children under 18, optional for adults)
I, hereby, give permission to RECA to obtain the services of a physician to provide prompt emergency medical treatment for(student) ______________________________ should the need arise.
Medical insurance carrier: ___________________________________________________________________________
Medical insurance number: ___________________________________________________________________________
Other instructions: _____________________________________________________________________________________
Parent/guardian signature: ________________________________________________________________________________
Required for children under 18