VPAC Summer SOULstice Camp
THIS REGISTRATION FORM IS NOT SECURING A SPOT. If your are selected in the lottery, you will be contacted if you are selected to participate. Students are selected in a lottery process. Parents and legal guardians must complete this form. Camp dates are June 13-August 5th with COMMUNITY PERFORMANCE August 6th, 2022. Camp fee is $300-$600 for 8 weeks total. Scholarships available. Spaces limited. One registration per child.
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Parent Name *
First and last name
Parent Email *
Parent Phone Number *
Parent Work Phone Number *
Parent Address *
Student Name *
First and last name
Student Email *
Student Phone number *
What age group? *
Required
Student Gender *
Required
Student Racial and/or cultural identity *
Are there any legal custody arrangements you must share? *
Does this student have siblings that are attempting to secure a spot in the camp? *
What language does your student most frequently use at home? *
Does your student need any additional support academically, emotionally, mentally, or physically to make camp as successful as possible? THIS IS NOT A DETERMINING FACTOR OF ACCEPTANCE. *
Please list ALL student medical conditions. If your student is required to take medication, please request and complete a Medical Consent form. *
Emergency Contact Name *
Emergency Contact Phone Number *
Relationship to Student *
ATHLETIC CONSENT FORM- The undersigned has read and understands the material contained in this form and hereby authorizes the student named above to participate in physical education and extra-curricular sporting activities including, but not limited to recreational sports (basketball, football, etc.), gymnastics, tumbling, dancing, etc. while enrolled in VPAC.By the very nature, athletic activities can put students in situations in which serious, catastrophic and perhaps fatal injuries may occur. These injuries could include, but are not limited to the following:❒Sprains/strains❒Head injuries❒Unconsciousness❒Disfigurement❒Cuts/abrasions❒Paralysis❒Fractures❒Loss of eyesight❒DeathStudents and parents must assess the risks involved in such participation and make their choice to participate in spite of those risks. No amount of instruction, precaution or supervision will eliminate all risk of injury. Although the school may suggest or recommend the use of certain equipment, the school does not guarantee that such equipment will be free from defects or protect the student from injury. By granting permission for your student to participate in athletic activities, you, the parent/legal guardian, acknowledge that such risk exists and assume these risks. Participation by your child is voluntary and is not required by the school. The undersigned has read and hereby agrees to hold​VICTORY PROJECT-BASED ACADEMICS & CAREER, its employees, agents, volunteers and/or sponsors and any other person, firm or corporation charged or chargeable with responsibility or liability, free and harmless from any and all claims, demands, damages, costs, expenses, loss of services, action and causes of action resulting from the use of facilities, equipment and participation by my student in the above named athletic activity, to the fullest extent of the law. *
STUDENT MEDIA RELEASE FORM- VPAC requests your permission to reproduce through printed, audio, visual, or electronic means activities in which your pupil has participated in his/her educational program. Your authorization will enable us to use specially prepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement of education programs through the use of mass media, displays, brochures, websites, etc. ​At most, we would use your child’s first name, last initial, and grade level​. a. I, as a parent or guardian, of the above named pupil fully authorize and grant ​VPAC​ and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as “Recordings”), for the purposes stated or related to the above. b.I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or guardian. c.I understand and agree that ​VPAC ​and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings. d.I understand and agree that ​VPAC ​and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above. e.I hereby release and hold harmless ​VPAC and/or its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above. Granting permission is voluntary. By checking yes, I confirm that I have read and understand the release and I agree to accept its provisions. *
COMPLETE DONATION: HAVE YOU COMPLETED THE DONATION? You understand there are NO REFUNDS and all donations will be made to VPAC (www.vpac2020.org). METHOD: Zelle (720-620-2316), CashApp ($VPAC2020) or Paypal (https://www.paypal.me/ausetmaryamali) ONLY. Must be in U.S. funds. Registration confirmation/receipt and further information will be emailed. Cancellations/Changes and Refunds: ALL DONATIONS ARE NON-REFUNDABLE. Do you agree? *
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