STEM3 Camp Application & Release Forms CAMP SELECTIONPlease select which camp and dates you are interested in having your child participate.2020 Virtual STEM Summer Camp: STEM! Art! Design!Week 1: 6/22- 6/26Week 2: 6/29- 7/3Both Week 1 and Week 2Student/ Camp Participant’s Information Child's First Name Child's Middle Name Child's Last Name Child's Date of Birth Date Format: MM slash DD slash YYYY Child's AgeChild's School NameChild's Grade In SeptemberChild’s Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneIs participant a current Help Group student or client? If so, which school or program?Parent Guardian #1 First Last Home PhoneCell PhoneWork PhoneEmail Parent Guardian #2 First Last Home PhoneWork PhoneCell PhoneEmail Will any siblings be participating in camp as well? (Note: a separate application is required for each participant) Yes No If yes, please list all siblings and their ages who will be participatingAdditional InformationWhat type of educational setting does your child attend? Regular Ed/Inclusion Special Education (part of day) Special Education (full day) Non-Public Special Ed School Private School Has a 1:1 aide at school What other services is your child currently receiving?Does your child have any specific diagnoses? Yes No If YES, please list each diagnosis, when the child was diagnosedIs your child on any medication? Yes No If YES, Please list medications, dosage & time of administration.Does your child have any, medical restrictions or physical restrictions? Yes No If YES, please explain.Does your child have a history of seizures? Yes No If YES, please explain.If YES, please explain.What are your child’s main areas of interest and favorite activities?What activities/tasks does your child NOT like to engage in or is restricted from participating in?Please list your child’s strengths or special talents (e.g. music, art, building things)?What are your goals for your child while they are involved with this program?If you have any other information that you feel would be helpful to us, or that you would like us to know, please feel free to add your comments to the area belowHow did you hear about the STEM3 Academy Summer Camp?Release and Waiver of Liability and Indemnity AgreementIn consideration of being permitted to participate in in any activities involved with The Help Group’s After School and/or Camp programs, the undersigned, for himself or herself and any participating student for whom I am a parent or guardian (the “Student”), as well as other parents, guardians, any heirs, assignees, next of kin, distributees, and legal representatives of the Student, hereby enter into this agreement (the “Agreement”). Please read the terms and conditions of this Agreement carefully, as they impose legal obligations on you. By the terms “you” and “your” we refer to participants in the Activities, as well as to a parent or guardian signing this Agreement properly on behalf of a student who at the time this Agreement is signed is under the age of 18. I certify that the named participant below is healthy and capable of participating in all activities without restriction. I understand that it is solely my responsibility to determine whether there is any medical reason that he/she should not participate in an activity. If there are limitations or restrictions from certain kinds of activities, please specify:1. I am aware that the Activities may be hazardous. I am voluntarily participating in these activities, or authorizing the Student to participate in these activities with knowledge of the risks involved. I hereby agree to accept any and all risks of injury, accident or fatality and verify this statement by placing my initials here:2. I, for myself, the Student, as well as any other parents, guardians, any heirs, assignees, next of kin, distributees, and legal representatives of the Student do hereby release, waive, discharge, and covenant not to sue The Help Group and all its affiliated entities and programs ( collectively “THG” ) and, its directors, officers, employees, and agents (collectively, “Releasees”) from all liability to the undersigned or the Student, and to any other parents, guardians, heirs, assignees, next of kin, distributees, and legal representatives of the Student for any loss or damage, and any claim or demands therefor on account of injury to the person or property or resulting in death of the undersigned or the Student, while the undersigned or the Student is participating in any way in the Activities. My initials here:3. I hereby agree to indemnify and save and hold harmless the Releasees and each of them from any loss, liability, damage or cost they may incur, including attorneys’ fees and costs, due to my participation in the Activity , or the participation of the Student, whether caused by the negligence of the Releasees or otherwise. My initials here:4. I hereby assume full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while I, or the Student is participating in any way in the Activity. My initials here:I further expressly agree that the foregoing Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have read this Agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this Agreement freely and voluntarily, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. Electronic Signature of Parents/Guardian of MinorElectronic Signature of Participant if 18 years of Age or OlderParticipant’s Age (if minor)Date Date Format: MM slash DD slash YYYY THE HELP GROUP POLICIES:POLICY REGARDING THE REPORTING OF CHILD ABUSECalifornia law requires that all professional who work with, care for, or otherwise come in contact with children, must report all known or suspected cases of child/dependent adult abuse and neglect. Abuse is defined as any instance of physical abuse, physical neglect, sexual abuse, or emotional maltreatment. If an employee of The Help Group has reason to believe that any kind of child/dependent adult abuse has occurred, a report will be made to the appropriate authority and parent/guardian will be notified.Please sign below that you have read and understand the policy regarding the reporting of child abuse.PHOTO/VIDEO/AUDIO/NAME RELEASE Yes, I consent No, I do NOT consent I hereby give consent for my child’s name and or the family surname to be used for public relations, fundraising, training, demonstration, and/or educational purposes by The Help Group. I waive any and all rights to compensation for any use of these media materials.TERMS OF ACCEPTANCE AND SIGNATUREI, parent or guardian of minor child, certify that I have read and understand the applicant instructions for The Help Group ‘s After school and/or Camp programs included with this application and that answers given by me to the foregoing questions and statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application. I understand that this application form is intended for use in evaluating me or my minor child’s qualifications for The Help Group ‘s After school and/or Camp programs and that this application is not considered as an acceptance to The Help Group ‘s After school and/or Camp programs . Abuse is defined as any instance of physical abuse, physical neglect, sexual abuse, or emotional maltreatment. If an employee of The Help Group has reason to believe that any kind of child/dependent adult abuse has occurred, a report will be made to the appropriate authority and parent/guardian will be notified.I, the (applicant, requestor, etc) for this release agreement, warrant the truthfulness of the information provided in this application.Electronic Signature of Parents/Guardian of MinorElectronic Signature of Participant if 18 years of Age or OlderDate Date Format: MM slash DD slash YYYY Participant’s Age (if minor)Consent* I agree“I authorize investigation of all statements contained in this Application to the program as may be necessary in arriving at an admission decision. In the event of admission, I understand that false or misleading information, given in the application of my child, or in any interviews, may result in rescission of any admission.”CAPTCHANameThis field is for validation purposes and should be left unchanged.
