Indian Pueblo Cultural Center

2013 Summer Day Camp Registration Form

To be completed by parent or guardian 1. All required information must be complete before registration is accepted 2. Make a copy for your records 3. Return completed form with your payment to IPCC 4. Submit one form per child 5. Children must be the stated age at the start of the session for which they are registering 6. Registration is complete upon receipt of completed registration forms and full payment

Session I: June 3-14, 2013 6-11yo Session II: June 17-28, 2013 6-11yo
Childs name Age (at time of camp)

Date of birth

F
Parent (Guardian) name(s) Home address State

City Zip code Home phone Work/ Cell phone

In case of emergency where a parent is not available, list two emergency contacts:
relationship relationship phone phone

Who is authorized to pick up your child at the end of the day? (Please include yourself and any other individuals you authorize who are at least 16 years old, with a valid drivers license. All those picking up a child will be required to come in to sign in and out.)

Indian Pueblo Cultural Center

2013 Summer Day Camp Consent Form

I, (Parent or Guardian) of hereby agree to allow my child to participate in the Indian Pueblo Cultural Center Summer Day Camp program. I understand and acknowledge that by allowing my child to participate in this program, I will be responsible for damage to the property of the Indian Pueblo Cultural Center museum and private parties caused by my child or any injuries to my child or other parties, which may result from his/ her participation in this activity. I, (parent or guardian) of give permission to the Indian Pueblo Cultural Centes education staff during field trips to oversee my childs transport to and from the museum to sites at a local Pueblo community. I, (parent or guardian) of hereby grant permission to the Indian Pueblo Cultural Center to take photographs and video of the child listed above while enrolled in the Indian Pueblo Cultural Center Summer Day Camp Program. I further understand and acknowledge that any photograph or video taken by Indian Pueblo Cultural Center staff members may be used in the Indian Pueblo Cultural Centers newsletter, web site, flyers, brochures, etc. Indian Pueblo Cultural Center may share photographs and videos with parents or guardians, however, original negatives and video will remain the property of the Indian Pueblo Cultural Center. Indian Pueblo Cultural Center retains the right to expel any child from the Summer Day Camp program, with cause and advance notice, if a child becomes unreasonably unruly or violent.

Parent / Guardian signature Please return with $250.00 per camper per session or $450.00 for two session participation to: Indian Pueblo Cultural Center Summer Day Camp Program 2401 12th St. NW Albuquerque, NM 87104 Please call: Kay Ortega: 505-212-7052 with any questions

Date

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2013 Summer Day Camp Authorization for Medical Treatment The Indian Pueblo Cultural Center wishes to avoid difficulties in obtaining medical services for children who may become ill or injured durring the 2013 Summer Day Camp Program. As the parent/ guardian of a child participating in this program, it is necessary that you consent, in advance, to hospitalization, medical attention or surgery for your child in case an emergency occurs. If no consent is given, you must provide a written statement of procedures to be followed if your child is injured or becomes ill during the 2013 Summer Day Camp Program. In the event of illness or injury, a reasonable effort will be made to contact you and designated emergency contacts to obtain consent in advance of medical services being administered. If we are unable to contact you, Indian Pueblo Cultural Center staff will consent to such services for your child by acting in your behalf based on written advanced authorization. That authorization is the consent form below. I, the parent/ guardian of have read the above and hereby designate Indian Pueblo Cultural Center staff to act on my behalf in the event of a medical emergency. He/ she may authorize such hospitalization, medical attention, or surgery as may be required in an emergency due to illness or injuries sustained by my child while participating in the 2013 Indian Pueblo Cultural Center Summer Day Camp Program. I hereby assume financial responsibility for ambulization, hospitalization, medical attention, and surgery provided. Medical Concerns (including allergies) of which Indian Pueblio Cultural Center staff needs to be aware: Prescription medication needed by student: Signature ______________________________________ Date ______________