2024 Mosaic Summer Camp Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

******Please complete a separate form for each child.******

Cost:

Registration: $30/family

One Child: $360 for all 6 weeks
Family Rate: $600 for all 6 weeks

Optional Late Stay: $220/family

Registration is required to reserve spot.
Fees can be paid via PayPal, Venmo (with fees), or in person at Mosaic from 4:00 - 5:30 pm

Dates: June 10th - July 26th
Hours: 8:00 - 2:30
Optional Late Stay: 2:30 - 5:30
Who: Rising Kindergarten - High School

*Kindergarten students must leave at 2:30 (no late stay).
*Breakfast and lunch is provided. Snack is provided for Late Stay students.

Child's Name *

Birthday *

YYYY

Age *

Grade Entering: *

K4 (FULL / WAITLIST ONLY)

K5 (FULL / WAITLIST ONLY)

First (REGISTERING 2017 BIRTHDAYS ONLY / WAITLIST FOR 2018 BIRTHDAYS)

Second

Third

Fourth

Fifth

Sixth

Seventh

Eighth

Ninth (Intern)

Tenth (Intern)

Eleventh (Intern)

Twelfth (intern)

Required

Allergies/Medical Concerns/Dietary restrictions, etc *

My children will attend Late Stay from 2:30 - 5:30:
(Kindergarten students cannot attend Late Stay, and must leave at 2:30) *

Yes

I do not need Late Stay for my child(ren)

Other:

Required

Address *

Parent/Guardian Contact Information (Name, Phone Number, Email, WhatsApp, etc) *

Emergency Contact (other than parents/guardian) - List name, number, & relation to child *

Please list anyone else authorized to pick up your child. *

Liability Waiver/Photo Release *

I grant permission for my child to participate on Field Trips and be transported by Aldersgate UMC Mini-bus, and driven by Andre' Webb. I release the staff, volunteers, and teachers of Mosaic Educational and Arts Program and Aldersgate UMC from any and all liability arising from claims of any kind of nature whatsover from my child's participation in this camp. In case of an emergency, if the above numbers cannot be contacted, I give permission for Mosaic Educational and Arts Program staff to make the appropriate medical decisions necessary to treat my child

I grant permission for Mosaic Educational and Arts Program to take photographs and videos of my child to be used for camp creations and online publicity.

Required

I agree to/acknowledge the following *

Students with a temperature of 100 F or higher may not stay at Mosaic. If a student spikes a fever of 100 F or higher during the day, a parent must pickup within 30 minutes.

If a student tests positive for COVID-19, they will quarantine for 5 days.

I acknowledge the health risks and dangers associated with the COVID-19 virus and other communicable diseases and recognize that exposure to either could occur while my child is in the care of Mosaic Educational and Arts Program.

I fully assume all of the risks associated with participation in the Mosaic Educational and Arts Program, including the possibility of COVID-19 community spread.

Required

I have read and understand and agree on behalf of myself and my minor child to be bound by the terms of this agreement. I certify this to be true by typing my name below. *

I will explain this information to my child, and have them type their name below in agreement *

Date *

YYYY

Please consider donating to our Summer Arts Camp Scholarship Fund. Type "Camp Scholarship" in memo.

Donate Now

If you are in need of a scholarship, please contact Ms. Laura or Mr. Andre'

Pay Now!

PayPal Giving Fund: No additional Fees

Venmo: Please pay total listed to cover fees
Registration (Venmo): $31.00

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Mosaic Educational and Arts Program. Report Abuse

Forms