Spring Break Camp Registration Form Spring Break Camp Registration We would love to hear from you! Please fill out this form and we will get in touch with you shortly. Student's Name* First Last Student's Birth Date* MM DD YYYY Child's Age*Male or Female*GradeChild's School*Mother's Name* Mom's Phone (Cell)*Father's Name* Dad's Phone (Cell)*Home Phone NumberBusiness Phone NumberEmail* Student's Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country How did you hear about us? Friend? Name of Advertisement? Online Ad?*EMERGENCY CONTACT NAME* Relationship to Student*Phone #*SPRING BREAK CAMP SCHEDULESession 1: April 3-7Weekly ($355.00) (S1)Camp Location: 633 Kensington Rd. Santa Monica, CA 90401Session 2: April 10 - 14Weekly ($355.00) (S2)Camp Location: 633 Kensington Rd. Santa Monica, CA 90401 Registration Fee$25 Registration/Materials Fee*I agree to the required Registration/Materials fee.Please list any special concerns: allergies, medication, health concerns We want your child to have the best possible experience at our camp, please share with us more about your child. List any information that is relevant to taking the best possible care of your child’s health: Allergies? Asthma? Health Concerns? Medication? Previous Injuries? Special Needs? Please put sunscreen on your child every morning before camp. We encourage children to bring their own sunscreen with them, and we will reapply your sunscreen throughout the day as well. I allow the instructors to apply sunscreen on my child. 2017 Spring Camp Enrollment Agreement (Please Read Carefully)* I have read, agree and understand all of the Registration Information and the Enrollment Agreement. Please Read Carefully •My child(ren) has my permission to attend camp, under the supervision of the Funky Divas & Dudes LLC. •I understand that a late charge of $25 applies if my child remains after 3:05pm sharp. •Funky Divas & Dudes LLC may use my child’s photograph/ likeness in promotional materials. •Any questions I have about Funky Divas & Dudes Camp has been answered to my satisfaction. •I understand there are absolutely no refunds or make-up days. •I agree to pay all tuition and fees set forth for Funky Divas& Dudes Camp. •If Funky Divas, in judgment believes my child(ren) requires medical attention, Funky Divas & Dudes LLC has my authorization to obtain such medical care from a licensed hospital or physician as they deem necessary. As the guardian, I will be responsible for all physicians, hospital and related costs so incurred. •On behalf of my child(ren) I voluntarily assume all risks of injury, loss, or damage that may be sustained and release and discharge Funky Divas & Dudes LLC, its officers, staff, employees, and residential hosts from all loss or damage and from any claim or demand on account of injury or death. •I agree to hold harmless, indemnify and defend Funky Divas & Dudes LLC, its officers, staff, employees and residential hosts for and from any and all liability, claims, expenses, demands, fees, judgments and/or damages arising directly or indirectly from my child(ren)’s participation in camp programs or at any time my child(ren) is on the premises of or premises used by Funky Divas, save and except claims arising out of the sole willful misconduct of Funky Divas. I will reimburse Funky Divas, it’s officers, staff, employees, agents and residential hosts for all expenses including reasonable attorney fees for all such claims made. •I hereby release Funky Divas & Dudes LLC, Dana Marie Lazzareschi & Kelly Lyans of any injury claims resulting from my child participating in the Summer Camp. I, the undersigned parent or guardian, grant permission to any physician, selected by the instructors to secure, at my expense, proper treatment, including but not limited to x-ray examination, anesthesia, medical and/or surgical diagnosis or treatment, and hospitalization if necessary for my child. I have read and understand all of the Registration Information and the Enrollment Agreement.Total amount due $0.00 Click the "submit" button below to register your child. You will be redirected to a payment option. Thank you.NameThis field is for validation purposes and should be left unchanged.