Your Information Student Name *
Parent/Guardian 1 Name *
Parent/Guardian 2 Name *
Emergency Contacts Alternate Emergency Contact *
Please provide necessary medical information about your child, including allergies, use of epi-pen, other concerns, etc. (medical release to be signed below): Authorized to Pick Up
The following individuals are authorized by parent(s)/guardian(s) to pick child up from EYC Summer Academy:
Contact Name *
Contact Name *
Program Selection Which programs would you like to sign up for? *
Select all that apply
Please select your payment option * Scheduling
For on-site tutoring programs, please choose your schedule and the weeks you are scheduling your student to attend:
Please select the weeks you would like to pay for *
Week 1: June 6, 7, 8
Week 2: June 13, 14, 15
Week 3: June 20, 21, 22
Week 4: June 27, 28, 29
Week 5:July (class 4th) 5, 6, 7
Week 6: July 11, 12, 13
Week 7: July 18, 19, 20
Week 8: July 25, 26, 27
Week 9: Aug 1, 2, 3
Week 10: Aug 8, 9, 10
Week 1 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 2 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 3 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 4 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 5 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 6 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 7 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 8 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 9 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Week 10 Time Selection * Please select a time 9am-11am 11am-1pm 1pm-3pm Test-Prep Course Quantity Media/Publicity Release
I give EYC Academy permission to audio, video, and photograph my child while participating at EYC Academy for the purposes of EYC Academy or any funder supporting the camp or activity without expectation of compensation or approval rights (i.e. brochure mailings, highlight promotional videos and photos for our website or social media).
Permission * Medical Release
The health and history are correct so far as I know, and the person described has permission to engage in all prescribed camp activities except as noted. In case of a medical emergency, if I (parent/guardian listed above) cannot be contacted, I hereby give permission to a camp representative to seek emergency treatment, including transportation by emergency vehicles. I further understand that every effort will be made to contact the camper's responsible parent or guardian. I authorize this form to be copied for emergency purposes. I further understand that if I do not have medical insurance that covers ALL costs, I will be responsible for such medical and travel expenses.
Attendance Policies *
All purchased hours must be used by Aug. 11th and will not carry over into the school year. Preferred scheduling is subject to instructor availability for specified subject or content and may not be available for all time slots. Any absences from scheduled sessions will be charged and no make-ups provided.
I agree to the Attendance Policy COVID19 Release *
I recognize that Corona Virus or COVID-19 is an extremely contagious virus that spreads easily through airborne and droplet transmission and person-to person contact and may be transmitted by individuals having no apparent symptoms of infection. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Federal and state authorities recommend social distancing to prevent the spread of the virus and I have been informed that EYC Academy and its staff have implemented guidelines of social distancing and routine disinfecting practices to minimize risk. However, I fully understand that participating in EYC Summer Academy at EYC Academy could increase the risk of contracting COVID-19. I, for myself and Minor, agree to comply with the rules and guidelines adopted by EYC Academy relating to COVID19 and hold harmless Empowering Youth and Communities, INC. EYC ACADEMY.
I agree to the COVID Release Waiver of Liability
In consideration of being permitted to participate in any way in the activities at and to attend EYC Academy, I, for myself, my child, my heirs, personal representatives or assignors, do hereby release, waive, discharge, and enter a covenant not to bring legal action against EYC Academy, its officers, employees and agents, from liability from any and all claims including the negligence EYC Academy, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to the activities and attendance at any camps or services at EYC Academy. The participation in activities at EYC Academy carries with it certain inherent risks that cannot be anticipated or eliminated regardless of the care taken to avoid injuries. Activities at EYC Academy's camps require a low level of physical fitness. I warrant that my child is physically fit and able to participate in all activities. I also agree to INDEMNIFY AND HOLD HARMLESS EYC Academy, its officers, employees, and agents from any and all claims, actions suits, procedures, costs, expenses, damages and liabilities, including attorney's fees, as a result of my child's attendance and involvement in any activities while at EYC Academy, including any claim asserted by my child after he/she becomes an adult. I also acknowledge that I have read the above and understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing freely and voluntarily and intend by my signature to a complete and unconditional release of all liability to the greatest extent allowed by law.
Payment Billing Address
How would you like to make your payment? * Credit Card