Camp Kellogg Registration Summer 2021 Step 1 of 5 20% Child's Name * Required Child's Age * RequiredGuardian Name(s) * Required Phone * RequiredBest Contact Email * Required Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Session 1 (June 7 - 11) Ages 8-13 (9:00am-4:00pm) Mural Arts & Land Acknowledgement (Calling all artists! Campers will create a large-scale Land Acknowledgement mural, depicting medicinal and edible plants native to these Ahtna and Dena’ina lands.) $285 Session 2 (June 14 - 18) Ages 7-13 (9:00am-4:00pm) Theatre Arts (acting skills and technical arts with a performance on Friday June 25) *Must entroll in weeks 2 & 3 of Theatre Arts Camp Because performance programming requires two weeks of camp- $255/week Ages 14-17 (8:45am-4:00pm) Leaders In Training (Behind the scenes, what happens at camp without the campers?) $125 Session 3 (June 21 - 25) Ages 7-13 (9:00am-4:00pm) Theatre Arts (acting skills and technical arts with a performance on Friday June 25) *Must entroll in weeks 2 & 3 of Theatre Arts Camp Because performance programming requires two weeks of camp- $255/week Ages 14-17 (8:45am-4:00pm) Leaders In Training (Language of Leadership, how does an outdoor enthusiast become an outdoor leader?) $125 Session 4 (July 12 - 16) Ages 10-13 (9:00am-4:00pm) Magic of Motion ( A creative exploration of movement and contemporary choreography (jazz, hip-hop, ballet, and modem dance) within the natural landscape) $285 Ages 14-17 (8:45am-4:00pm) Leaders In Training (Balance in Leadership, how can a give and take environment be beneficial?) $125 Session 5 (July 19 - 23) Ages 9-13 (9:00am-4:00pm) Battle of the Big Five (various games of body, mind, creativity) $285 Ages 14-17 (8:45am-4:00pm) Leaders In Training (Everlasting Experience, when does a leader stop learning?) $125 Cancellation and Refund Policy * Required I understand and agree. There is a non-refundable $50 deposit, per camper, per week of registered camp. The deposit is applied to the camp cost. If you cancel two or more weeks prior to camp, you will receive a 100% refund (less the non-refundable $50 deposit) If you cancel within two weeks of the camp start date, you are responsible for 50% of the total camp cost if we are unable to fill the spot. If you withdraw from camp after the start date, there is no refund. Camper T-shirt Size (included with camp cost) * Required Youth XS Youth S Youth M Youth L XS S M L XL Additional Friends & Family T-shirts ($15 each)Only one additional allowed from the website Youth XS Youth S Youth M Youth L XS S M L XL XXL Additional t-shirt orders (repeat sizes) here Physician * Required Physician Phone NumberInsurance Company * Required Insurance Policy #/ID # * Required Emergency Contact Name * Required Emergency Contact Relationship * Required Emergency Contact Phone * RequiredDoes your student have allergies to any of the following? * RequiredSelect all that apply Insect Bites/Stings Foods Environmental Medicines No Known Allergies Please provide detail about the allergy, its severity, and its management * RequiredDoes your student have a history of any of the following conditions? * RequiredSelect all that apply Heart Defect/Disease Diabetes Hypertension Epilepsy Bleeding/Clotting Disorders Asthma Mental/Emotional Illness Skin Conditions No Known Medical Conditions Please provide greater detail about the condition, its severity, and its management * RequiredIs your student currently taking any prescription medications? * Required Yes No Details * Required Is there any important health information that we missed? COVID Protocol & Procedures * RequiredCamp will primarily be held in our outdoor classroom spaces. While learning and exploring outside, the children will not be required to wear masks. However, when inside the classrooms, both instructors and children will need to wear masks that cover their nose and mouth. At the instructor’s discretion, students may be asked to wear their masks outdoors temporarily for brief teachable moments. At drop off, Camp Instructors will have you verify that your child, everyone in your home and close contacts have NOT had the following in the past 72 hours: Fever (100.4 degrees F or higher) Sore throat Persistent Cough Trouble breathing Professional cleaning of bathrooms and shared spaces will take place on a weekly basis. After class each day, common surfaces, doorknobs, and light switches will be sanitized. I understand and agree Photo Release Form * RequiredI grant Alaska Pacific University and its representatives and employees the right to take photographs of my child and his/her property in connection with Camp Kellogg programming. I authorize Camp Kellogg, its assigns and transferees to copyright, use and publish the photographs in print and/or electronically. I agree that Camp Kellogg may use such photographs of my child with or without his/her name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and/or web content. I agree I do not agree Consent for Emergency Medical or Surgical Care * RequiredIn the rare event of an emergency, I hereby give my permission to the medical personnel selected by the program director to provide routine health care; to administer medications; to order x-rays, routine tests, treatment; to release any record necessary to insurance purposes; and to provide or arrange necessary related transportation for me/my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for the person named above. This form may be photocopied for trips away from campus. All information is strictly confidential. Camp Kellogg does not cover accident insurance coverage for participants; you must carry your own accident insurance coverage. I authorize the above information for insurance purposes. It is understood that a conscientious effort will be made to locate me or my child's other legal guardian. I understand my obligation to keep Camp Kellogg informed of my whereabouts. I will assume the cost of necessary medical or surgical care. I agree I do not agree Authorization to Participate * RequiredMy son/daughter/dependent has permission to participate in all Camp Kellogg activities. I recognize that my child will be participating in active, outdoor programs with other children and that accidental injuries and illnesses may result. I assume the inherent risks of, but not limited to, the following: running, hiking, skiing, snow shoeing, ice skating, dog mushing, group games, wildlife, and inclement weather, and authorize my child's participation. Camp Kellogg instructors do not provide transportation to participants. I understand that I am responsible for transporting my child to any activity occurring off-site. If I am unable to attend, it is my responsibility to arrange a ride-share with another parent or guardian. On occasions, photographs of participants are used for publicity purposes or included in grant applications submitted to charitable foundations. I authorize Camp Kellogg to use photographs taken for these purposes. Camp Kellogg is hereby released from all claims, liability, and losses for actions taken in good faith during this program. I agree I do not agree I HAVE READ ALL QUESTIONS INCLUDED IN THIS FORM THOROUGHLY, AGREE TO ITS TERMS AND I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE AND COMPLETED TO THE BEST OF MY KNOWLEDGE. * RequiredIf you agree to the above statement, please type your name in the dialogue box below. Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Δ
