Steelworks Science Summer Camp 2016

June 26-June 30, 2017

Registration Form

Student Name:______

Mailing Address:______

I will be entering ______grade Gender ______

School ______

Emergency Contact Name ______

Emergency Contact Phone ______

Relationship ______

Emergency Contact #2 Name ______

Emergency Contact #2 Phone ______

Relationship______

The fee for this camp is $100 for the week

Total Payment Enclosed: $______

Method of Payment:

Cash [] Check [] Check # ______

Credit card: Visa [] Mastercard []

Credit Card #______Expiration date ______

Signature ______

Steelworks Museum Science Camp 2016 Commonly Asked Questions

Where will the science camp be held?

The camp will be held at the Steelworks Museum, 215 Canal Street, each day. The camp will be held Monday June 26 to Friday June 30, 2017 from 9:00-3:00. Students must be picked up by 3:15.

What about lunch?

Students should bring a sack lunch each day. Activities will break at about 12:00 each day for 45 minutes. Please let staff know about food allergies or other food concerns (i.e. my child is diabetic; my child is allergic to nuts).

How will I pick up/drop off my child each day? For your child’s safety all students must be signed out of the museum by a parent or guardian or authorized adult each day. Only adults who are listed on the pick-up authorization form will be allowed to take your child home. If you need to add someone to the list, please notify staff in writing. These measures are for your child’s security, we must insist on your cooperation.

How should my child dress for camp? In comfortable clothes that may get messy. For safety, we recommend closed-toe shoes.

Who can I contact during the day if I need to leave a message concerning my child? You can call the Steelworks Museum at (719) 564-9086 ext. 110 and a staff member will deliver your message to the appropriate person.

What are the behavior expectations for campers? Students participating in the camp are expected to behave in a responsible, mature and appropriate manner, as if in a school classroom. Students are expected to listen and follow directions, respect instructors, teaching assistants, and other students in the camp, respect and maintain the Steelworks Museum property including classroom and gallery space, supplies and other equipment, participate in activities, work cooperatively in groups, and ask questions. In the event of a severe behavior problem, we will call you to pick up your child. At our discretion, your child may or may not be allowed to return to camp the following day. Students will be automatically dismissed from the program for the use of drugs, alcohol, cigarettes, weapons or for engaging in theft, vandalism or violent behavior or behavior that appears to be disruptive towards adults, other students in the camp and museum property. We do not tolerate bullying of any kind. Please let your child know it is ok to talk to an adult if they feel they are being bullied.

Absences

The five day long camp is designed so that subject matter builds upon itself each day. Tuition cannot be refunded or pro-rated if your child is absent. Make up classes are not offered. We have reserved space for each child exclusively during the week and maintain a waiting list for those who register after the space is full.

Medication for students

If your child requires medication, Steelworks Museum staff and volunteers will not dispense it to your child. If your child regularly dispenses medication to him/herself and you feel comfortable allowing him/her to do so, they will be allowed to do so. If not, you or another trusted adult will be required to come to the museum and dispense the medication.

Signature of Confirmation

I have read and understood The Steelworks Museum Summer Camp Registration Packet and shared this information with my child who will be participating in the program. We agree to follow the guidelines stated in the packet.

______

Parent/Guardian Signature Date

______

Student Signature Date

Please return this form (along with others) to:

Victoria Miller, Curator

Steelworks Museum

215 Canal Street

Pueblo, CO 81004

Fax: 719-564-9681

Student’s Name ______

Doctor’s Name______Phone (____)______

Does your child routinely require medication? Yes _____ No _____

Preferred hospital: ______

Important: Please describe any special health considerations including, but not limited to, allergies, physical or behavioral conditions that may affect your child’s participation in this camp.

1. Allergies

2. Medical concerns (medication, past health problems, etc.)

3. Limitations on activities:

4. List any behaviors of which staff should be aware. How do you handle this behavior?

(If additional space is needed for any of the above, please use back of this page or contact the Steelworks Museum Curator directly at (719) 564-9086 ext. 108)

Student’s Name______

ASSUMPTION OF RISK, RELEASE AND INDEMNITY AND

HOLD HARMLESS AGREEMENT

In consideration for enrolling my child in the Steelworks Museum Summer Camp, I agree on behalf of myself, my child, my spouse (if any) to be bound by the following terms and conditions.

1. Assumption of Risk. I am aware of inherent and other risks involved in my child’s participation in the Program (including, but not limited to, injury, death, or property damage) and I hereby assume any and all risks, whether known or unknown to me at this time, of injury, death, and property damage that may result from my child’s participation in the Program.

2. Release of Liability. I hereby release the Steelworks Museum (DBA Bessemer Historical Society), its directors, officers, agents, representatives, employees, and contractors from and against any and all claims, or damages arising out of or in connection with my child’s participation in the program. This release includes, without limitation, any claims arising in negligence, other sort, or contract.

3. Hold Harmless and Indemnity. I hereby agree to defend, indemnify and hold harmless the Bessemer Historical Society (DBA Steelworks Center of the West), its directors, officers, agents, representatives, employees and contractors from and against any claims, damages, liabilities, costs and expenses (including, without limitation, reasonable attorney’s fees) arising out of resulting from or incurred connection with my child’s participation in the program.

4. Photography. My child may be photographed for media and publications including the organization’s grant reports, annual reports, Facebook page, website, and newsletter.

Yes _____ No _____

Having read this Agreement, understanding its terms and desiring to allow my child to participate in the program, parent agrees to be bound by the terms of this agreement. The Steelworks Museum accepts no responsibility for losses or expenses beyond our control, e.g. weather. All such losses must be borne by the participant’s parents.

Parent/Guardian Name (Print): ______

Signature :______

Student Name______

The following persons are authorized to pick up my child from the Steelworks Museum Summer Science Camp:

1. ______

2. ______

3. ______

Parent signature______

For the Student:

Name ______

Please answer out the following questions.

a. What is your favorite subject(s) in school?

b. What type of math or science topics interest you the most? Why?

c. What fun math or science websites, magazines, or tv shows do you enjoy or would recommend to your friends?