Day Camp Registration Form for Rising 2nd‐6th Graders Please complete fully and return to: ERC * P.O. Box 819 * Ketchum, ID 83340. Questions 208‐726‐4333 Name of Participant: ____________________________________________________Male/Female:_____________ Grade for 2014‐2015 School Year: ___________________ Parent/Guardian Name:___________________________ Phone Number:________________________ Email Address:_____________________________________________ Mailing Address: _______________________________________ City, State & Zip:___________________________
Other Emergency Contact Name & Phone:___________________________________________________________ Contact’s Relationship to participant:________________________________________________________________ Health & Safety Information: Medical or Behavioral Issues: ___________________________________________________________ Please circle all that apply: Takes medication Allergies Other If circled, please explain: _______________________________________________________________
Camps and Dates (Mark camp alone or camp plus field trip): Lift Off: The Science of Flight June 16‐19 _____ Camp $175 or ______with Friday Field Trip $225 Secrets of Underwater Life July 7‐10 _____Camp $175 or ______with Friday Field Trip $225 Night Stalkers, Day Risers August 11‐14 _____Camp $175 or ______with Friday Field Trip $225
Payment Information Discounts Available:
ERC Membership Discount: $25 Discount per child/per week (ERC family annual membership cost is $50. Call us at 208‐726‐4333 if you have questions.)
Confidential scholarships & payment plans available. _____ Please email me a scholarship application. A deposit of $100 per camp is required to secure your registration. With scholarship application, a $50 deposit is required (refundable if we are not able to meet your scholarship needs). Cancellation policy ‐ up to four weeks before start of camp: all but $50 administration fee refunded. Less than four weeks before start of camp, no refund. Payment Method: __Check __MasterCard__ Visa __Amex __Discover Name on Card:_____________________________________________________________________________ Card Billing Address:___________________ _________________City, State, Zip:________________________ Credit Card Number:_________________________________________________________________________
Security Code from Card: _______________ Expiration: ________________________ Email for receipt:_______________________________________________________________