Camp ISANA Step 1 of 6 16% CAMP ISANA ATTENDANCE OPTIONS:While completing the application you will be asked to designate a daily attendance option for your child. Your child’s enrollment and schedule for the duration of CAMP ISANA (June 26 – July 21) will be based upon your selection: • Attendance Option #1: Monday – Friday 9am – 1pm • Attendance Option #2: Monday – Friday 9am – 4pm The Education Code states the intent of summer programs like the Expanded Learning Program is for students to participate in the program every day. Students must attend the program every day for the full range of hours selected to continue enrollment. Students are subject to dismissal from the program if these Program Attendance Requirements are not met. Pick-up and Dismissal: The program ends at 1:00pm each day for half day scholars and 4:00pm each day for full day scholars. If you expect to arrive late, please contact your child’s school as soon as possible. Authorization for Student Pick-Up: Parents/guardians may authorize additional adults to pick-up their child on the Authorization for Student Pick-Up Sheet. ISANA will not release students to individuals younger than 18 years old or to individuals who are not authorized by parents/guardians for pick-up on this form. Email* I have read and understand all of the information above. I agree to follow of all these rules and help my son/daughter understand and follow the rules.* Yes No CAMP ISANA: Our voluntary CAMP ISANA Summer Enrichment Program is offered through the Expanded Learning Department. CAMP ISANA will provide students with academic enrichment, physical and safety enrichment, social enrichment, a healthy lunch, and off site field trips. Students are supervised by highly trained and qualified ISANA staff. • Please designate your child’s CAMP ISANA attendance option*Half Day: 9am – 1pmFull Day: 9am – 4pmCurrent Grade*Select a GradeTKKindergarten1st2nd3rd4th5th6th7th8thStudent's Last Name* Student's First Name* Student's Middle Name Existing ISANA Student?* Yes No StudentID* The same as Clever login (numbers only)Student Date Of Birth:* MM slash DD slash YYYY Sex* Male Female Shirt Size*Select a SizeYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XXLEthnicity* American Indian/Alaskan Native Asian Native Hawaiian or Pacific Islander Black/African American Hispanic/Latino White Check all that applyStudent InfoAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian#1: First Name* Parent / Guardian#1: Last Name* Parent /Guardian #1: Relationship*Mother/StepmotherFather/StepfatherAunt/UncleGodparentGuardianFoster ParentOtherParent /Guardian#1:Home Phone #*Parent /Guardian#1:Cell Phone #Parent /Guardian#1:Work Phone #Parent/ Guardian # 1: Email* Parent / Guardian #2: First Name Parent / Guardian #2: Last Name Parent /Guardian #2: RelationshipMother/StepmotherFather/StepfatherAunt/UncleGodparentGuardianFoster ParentOtherParent /Guardian #2: Home Phone #Parent /Guardian #2: Cell Phone #Parent /Guardian #2: Work Phone #Parent/ Guardian #2: Email Does the student have an IEP?*Make a selectionYesNoDoes your child qualify for Free or Reduced lunch?*Make a selectionYesNo Court / Custody OrdersIs there a custody concern regarding this student?*Make a selectionYesNoIs there a current court order concerning this child?*Make a selectionYesNoIs the order still valid for this school year?*Make a selectionYesNo Sign-out AuthorizationIndividual #1: Complete Full Name* Individual #1: Relationship*Make a selectionMotherFatherGrandparentAunt/UncleGodparentSiblingGuardianFriendNeighborCoworkerOtherIndividual #1: Phone Number*Individual #2: Complete Full Name* Individual #2: Relationship*Make a selectionMotherFatherGrandparentAunt/UncleGodparentSiblingGuardianFriendNeighborCoworkerOtherIndividual #2: Phone Number*Individual #3: Complete Full Name* Individual #3: Relationship*Make a selectionMotherFatherGrandparentAunt/UncleGodparentSiblingGuardianFriendNeighborCoworkerOtherIndividual #3: Phone Number*Individual #4: Complete Full Name Individual #4: RelationshipMake a selectionMotherFatherGrandparentAunt/UncleGodparentSiblingGuardianFriendNeighborCoworkerOtherIndividual #4: Phone NumberIndividual #5: Complete Full Name Individual #5: RelationshipMake a selectionMotherFatherGrandparentAunt/UncleGodparentSiblingGuardianFriendNeighborCoworkerOtherIndividual #5: Phone Number Medical InformationIs the participant allergic to any medication(s)?* Yes No Please list medication(s):Does the participant have any dietary restriction(s)?* Yes No If participant has dietary restriction(s) and/or has food allergies, please list restrictions:Does the participant have any medications stored in the school office?* Yes No Please list medications Parent/Guardian AcknowledgementParent/Guardian Acknowledgment: By signing below, you agree to the following as parent/guardian of a child participating in the CAMP ISANA Program: • I acknowledge there are risks inherent with my child’s participation in the voluntary CAMP ISANA, which may involve physical activities. On behalf of myself and my child, I voluntarily assume all risks and hereby release, waive, hold harmless, discharge, and covenant not to sue ISANA (including its Board, employees, officers, volunteers, instructors, and agents) from any and all liability, claims, actions, and demands for any cause of action arising out of, related to or in any way connected to any loss, damage, or injury that may be sustained by my child or to any property belonging to my child, arising from my child’s participation in the program. • I understand ISANA reserves the right to cancel or change CAMP ISANA activities when necessary. • I understand ISANA is not responsible for the loss or damage to my child’s personal belongings. • In order to make each student’s participation a fun, safe and rewarding experience, we hold high expectations for student attitude and behavior. I agree that my child must follow ISANA’s conduct and disciplinary rules. (same rules that apply during the school day) I hereby perpetually and irrevocably grant to ISANA the right, permission, and license to record my child’s likeness and/or voice during CAMP ISANA activities with still photography, film, videotape, digital recording or storage device and to edit such recordings at ISANA’s discretion, and to use, reproduce, display, and/or distribute, and/or to make derivative works, with or without the pupil’s name, from the recordings for educational, promotional and fundraising purposes* Yes No I authorize my child to be released to those individuals listed on this registration form at the close of each program day and in case of emergencies. I understand that my child must be signed out by a parent/guardian or approved adult who is 18 years or older and are listed on this registration form.* Yes No I understand that in case of emergencies, CAMP ISANA will make every effort to contact the parents/legal guardians before any treatment is given. In the event that we cannot be contacted, I hereby authorize the physician or hospital selected by CAMP ISANA hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. It is further understood that I will assume full responsibility for any such treatment, including the payment of all costs and transportation and will hold the CAMP ISANA Site Coordinator and After-School Staff, harmless therefrom.* Yes No I agree to the terms, guidelines, and conditions of the program's Code of Conduct.* Yes No I have read this release of liability and assumption of risk agreement, I fully understand its terms, I understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.* Yes No I have read all the above and agree to all terms and conditions of my child's participation in the program. I confirm that all the information above is accurate and will provide and updated Student Registration Form if any information changes.* Yes, I have TYPE FULL LEGAL NAME BELOW* CommentsThis field is for validation purposes and should be left unchanged. Δ