Chinese Culture Summer Camp at IUPUI

2011 REGISTRATION FORM

Confucius Institute in Indianapolis                                                                 (Please Type or Print)

Today’s Date:

INFORMATION

Child’s Last Name:

First:

Middle:

Sex:  Male  Female

Age:

Birth Date:

Grade in Sept. 2011:

Street address:

City:

ZIP Code:

State:

1^st Parent/Guardian Name:

Home phone no.: (     )

Cell phoneno.: (     )

Work phone no.:  (     )

Email.:

2^nd Parent/Guardian Name:

Home phone no.: (     )

Cell phoneno.: (     )

Work phone no.:  (     )

Email.:

Emergency Contact: (Please provide the name of someone NOT listed above - parents/guardians listed above will always be contacted first)

Emergency Contact 1 Name:

Relationship:

phone no.: (     )

Emergency Contact 2 Name:

Relationship:

phone no.: (     )

Parent Guardian Consent The following individuals are authorized to pick up my child at the end of the camp day. (Authorized adults must present a photo ID for pick-up.)

1 Name:

Relationship:

phone no.: (     )

2 Name:

Relationship:

phone no.: (     )

SESSIONS & rATES

(Please SELECT THE ATTENDING WEEKS.)

Standard Weekly Rate:

Please x the selected week(s):

S

$150 per week x      week(s)

Week 1   2  3  4  5

Five Weeks Discounted Rate:

S

$125 per week x 5 week(s) = $625 (July 5 – August 5, Monday-Friday)

Pre & After School Care Rate:

Please x the selected week(s):

S

$25 per week   x      week(s) (7:30am – 8:30am/4:15pm-6:00pm

Week 1   2  3  4  5

Material Fee:

S 15

$15 (includes items such as t-shirt, books, calligraphy set and shuttlecock)

-$25 (one-time) Early Bird Discount For Those Enrolling before March 13^th

-S

-$30 For Those Enrolled for Week 1 Only.  No Camp on Monday July 4^th

-S

TOTAL:

S

I understand that I will be providing lunch for my child/ward for the duration of the summer camp. I also understand that I am expected to pick my child/ward up from the summer camp by 4:15pm unless arrangements have been made for his/her after hour’s care. I will be charged a fee for child care at the daily rate of $10 per child if the child/ward is not collected by 4:30pm. Fees are non-refundable after the camp begins.

Please list any previous Chinese learning experience your child has.  Please let us know how you heard about our Chinese Summer Camp at IUPUI Health Release/Special Circumstances: I give my permission for Riley Hospital for Children –Emergency Department to render any emergency medical treatment necessary for my child/ward during the Chinese Culture Summer Camp. Parent’s Signature ______________________________ Please list any special circumstances, allergies, or health problems your child has, or medication your child takes. Insurance Waiver (from Chinese Culture Summer Camp at IUPUI) In consideration of my child’s or ward’s participation in the Confucius Institute Chinese Summer Camp at IUPUI, I, intending to be legally bound, do hereby for myself, my spouse (if any), my child, my ward, and my child’s or ward’s executors and administrators, waive, release, hold harmless, and forever discharge the Confucius Institute, Indiana university, IUPUI, its agents, employees, representatives and sponsors of and from any and all claims, damages, or expenses, including without limitation, any claims, damages or expenses for loss, damages or injury to my child’s or ward’s person or property, arising or alleged to arise from any act or omission of the Confucius Institute, Indiana University, IUPUI, its agents, employees, representatives and sponsors; irrespective of whether such claim, damage, or expense is caused or alleged to be caused by the sole, joint, several or comparative negligence or any other breach of duty to the aforementioned organizations or individuals. I also give my permission to the aforementioned organizations for the free use of my likeness and that of my child or ward, in connection with any broadcast, telecast, print media account, or other publicity of or generated by the Confucius Institute.

Parent/Guardian signature

Date

Please send the registration form and the sign page to the following address:

Noah Buonanno

(317-278-7900)

Confucius Institute in Indianapolis

Cavanaugh Hall 129, 425 University Blvd

Indianapolis, IN 46202

Or

Fax to 317-278-7919 / Email to ciindy@iupui.edu