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E-Mail Address:  
 



Online Registration/Health Form:

Complete the form below and continue to online payment via Paypal. Or to view a printable registration form and to send payment (check/money order) click here.

Mailing Address:
Summer Solutions, Inc.
c/o Paul Basdekis
45446 Conductor Terrace
Sterling, VA 20166

Summer of 2010:
Camp Dates: July 11th to July 22nd
Location: To Be Determined
Camp Hours: 10:00AM to 4:00PM
Extended Hours Program: 8:00am to 10:00am / 4:00pm to 5:00pm
Ages: 8-13 (14-16 C.I.T. Program)

Summer Camp Registration Period: March 1st to July 1st (space is limited)
Early Registration Period: March 1st to May 1st

Full Name:
Parent E-Mail Address:
Date (XX/YY/ZZ):
Birth Date (XX/YY/ZZ):
Age:
Grade Entering:
School:
Male/Female: Male Female
Home Address:
City, State, Zip
  
Father's Name:
Home/Work Phone:
Cell:
  
Mother's Name:
Home/Work Phone:
Cell:
  
How did you hear about the program?:
  
Emergency Contact:
Phone:
  
  

T-Shirt Size

Youth M
Youth L
Youth XL
Adult M
Adult L
Adult XL
Adult XXL
  
  

Camp Dates, Sessions and Prices

Full Registration - $200/week = $400
Both Sessions: 07/11 - 07/22

Single Week Registration - $250 each week selected
Week 1: 7/11 - 7/15
Week 2: 7/18 - 7/22
  
Form of Payment: Credit Card Check/Money Order
  
*mail payment (check/money order) with registration to:
Summer Solutions Inc.; c/o Paul Basdekis;
45446 Conductor Terrace; Sterling, VA 20166
  
  
Health History:
(Please explain any chronic or recurring illnesses or medical condition)
  
Present Pertinent
Health Data:
(List specific allergies to food or medication and treatment. List any special dietary regimen, medicine your child is taking, psychological problems, learning disabilities, fears, difficulties adjusting to new situations, etc.)
  
Name and telephone number of regular physician or health care facility:
Name:
Phone:
  
  
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. AUTHORIZATION FOR TREATMENT: In the event I cannot be reached in an emergency, I hereby give permission to the Physician selected by the Camp Director to secure and administer treatment, including hospitalization, for my child as named above.
Signature of Parent or Guardian and Date:
(Typing your name in acts as your signature)



Camp Participation Waiver Form:
Release, Waiver of Liability, and Covenant Not to Sue
(TO BE SIGNED BY PARENT OR GUARDIAN)
Applies only to: Pro-Active Summer Camp


I hereby give permission for my child ___________(name of camper) to participate in all of the activities and field trips selected for Pro-Active Summer Camp. I hereby acknowledge my awareness that my child’s participation in these field trips may involve risks of property damage, and of bodily or personal injury, or even death. These risks may include motor vehicle accidents, sprains, bruises, falls, broken bones, and drowning, as well as other risks that may not be foreseeable. I hereby assume any and all such risks. I further agree on behalf of myself, my heirs, and personal representatives, that Pro-Active Summer Camp, along with its members, officers, directors, or employees shall not be liable for any injury, loss of life or other loss or damage occurring as a result of participation in the camp program. I hereby give my consent to Pro- Active Summer Camp to provide, through a medical staff of its choice, customary medical attention, transportation and emergency medical services as warranted in the course of participation in the activities of the summer camp. I certify that my child will be participating in the program with my full knowledge and consent and that I have read and understood the above.

Signature (Parent/Guardian):
Relationship To Child:
Child's Name:
Date:
Check this box to give your consent that your child may be photographed during the camp sessions. Photographs will be used in future brochures and on the camp website for advertising purposes.