Family ASTRO Star Explorer Camp at Clair Tappaan Lodge or Mini Camps at Sky Tavern

Family / Student Registration Form (you can print this form directly) Please mail signed completed application and full registration fee to: (Please make checks payable to Space Science for Schools)  Please send a fax copy of the original to 775-831-6994  Mailing Address:  Space Science for Schools, Inc., 930 Tahoe Blvd., #802-520, Incline Village, NV 89451

For questions, please call Cindy F. Smith at 775-356-8865 or csmith@ss4s.org  Note: Non-refundable deposit of $25 must be sent with application to reserve a date below.  Full payment by personal check must be submitted 1 month prior to the event to assure accommodations and program.

Please mark your preference-  Registration for Family ASTRO Star Explorer Camp at Clair Tappaan Lodge:

[  ] July 11-13                      [  ] August 1-3                      [  ] Oct 11-13  

Attending Parent/Guardian Name ___________________________Legal Custody □ Yes □ No

Address _____________________________________________

City _______________________ Zip _____________

Home Phone ____________Work Phone ___________Cell Phone _________________

1. Camper’s Name______________________________________ Age ____________

Address _____________________________________________

City _______________________ Zip _____________

Home Phone _______________________ Date of Birth ____________________

2. Camper’s Name _____________________________________Age_____________

Address _____________________________________________

City _______________________ Zip _____________

Home Phone _______________________Date of Birth ____________________

In case of emergency contact:

Name _____________________________ Relation __________________________

Home Phone ______________Work Phone ______________Other Phone _________________

Are you on our mailing list? □ Yes □ No Email Address _____________________________

In consideration of Space Science for Schools, Inc., and hosting entities (Clair Tappaan Lodge, or Sky Tavern of the City of Reno) granting the above-named child (ren) (“minor”) and myself the opportunity to participate in the camp program described in the brochure, (“Program”) I, (print name) ___________________________________________

the undersigned, as parent or legal guardian of the Minor do hereby agree as follows:

I am aware that there are certain risks of injury and/or damage inherent in the program’s activities;

I will follow and instruct minor to abide by all safety regulations and to take reasonable precautions to minimize risks of injury or damage arising from participation in the program;

I give my consent and my minor to participate in all aspect of the program and I knowingly assume full responsibility for all risks of bodily injury, death or property;

I understand that the Space Science for Schools and hosting entities has no obligation to obtain medical treatment for myself and the minor. Should it be necessary to have emergency medical care while participating in the program, I hereby give the Space Science for Schools and hosting entities permission to use their judgment in obtaining medical care and I give permission to the medical care provider selected by the Space Science for Schools and hosting entities personnel to render medical care deemed necessary and appropriate;

I understand that the Space Science for Schools and hosting entities at its sole option but without obligation may procure insurance to cover all or part of such medical expense incurred by myself or minor. Accordingly, I understand and agree that any cost incurred for such treatment which is not covered by insurance shall be my sole responsibility;

I also authorize the Space Science for Schools and hosting entities to make, procure to use photographs, films, tapes or other likeness of myself and the minor’s physical image and/or voice as may be needed for use with program’s public Space Science for Schools and hosting entities materials;

Except for the gross negligence or willful misconduct by Space Science for Schools and hosting entities, I waive all rights of recovery, which Minor or I may have now or in the future, whether known or unknown, against the Space Science for Schools and hosting entities or its officers, agencies or employees, and I release, acquit and forever discharge the Space Science for Schools and hosting entities from any and all liability for any bodily injury or other personal injury, damage, loss or expense, claims, demands causes of action, money damages, costs, loss of services or use, compensation, debts, including attorney fees, which result from or are in any way connected with myself or minor’s

participation in the program or any related activities.

I have carefully read this agreement. I understand what it means and my signature below is my own free act. I intend it to be legally binding on minor and myself. I also acknowledge that I have read and understand the payment, refund and condition of enrollment policies found in this brochure/flyer.

Important: Parent Signature is Required:

 ___________________________________________________________________________________

Parent/Guardian Name ( PRINT ) Signature

 ___________________________________________________________________________________ 

____________________________________________________________________  ______________

Child’s Name (PRINT)                                                                                                                                 Date