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250 <strong>Hofstra</strong> <strong>University</strong> I Hempstead, NY 11549-2500 I Phone: 516-463-CAMP I Fax: 516-463-6114 I Email: CE-CAMPS@hofstra.edu<br />

Website: hofstra.edu/camp I Twitter: @HU<strong>Summer</strong><strong>Camps</strong><br />

Office Use Only – Reg<strong>is</strong>tration Number:<br />

Last Name (Camper) First Name (Camper)<br />

Date of Birth Age Grade (as of Sept. 2013)<br />

SESSION(S) ATTENDING<br />

q Session 1 (July 1-12, 2013)<br />

q Male q Female<br />

Mailing Address (Street) City State ZIP<br />

Home Phone Number Parent Email (An email address <strong>is</strong> requested for all camp correspondence, bus pass, etc.)<br />

Name (Mother/Guardian) Work Phone (Mother/Guardian) Cell Phone (Mother/Guardian)<br />

Name (Father/Guardian) Work Phone (Father/Guardian) Cell Phone (Father/Guardian)<br />

Emergency Contact Name Emergency Contact Number Name(s) of sibling(s) who are reg<strong>is</strong>tering<br />

Do you require transportation? q Yes q No<br />

Area Pickup Location (if not getting door-<strong>to</strong>-door transportation)<br />

1) 2)<br />

Cross Streets<br />

T-shirt size (Choose one.) Youth: q M q L Adult: q S q M q L q XL q XXL<br />

SPECIALTY CAMPS RECREATION GROUP REQUEST<br />

We will attempt <strong>to</strong> accommodate your recreation group requests.<br />

Please do not request more than three campers.<br />

1)<br />

2)<br />

3)<br />

q Session 2 (July 15-26, 2013)<br />

q Session 3 (July 29-August 9, 2013)<br />

q Session 4 (August 12-16, 2013)<br />

Th<strong>is</strong> Reg<strong>is</strong>tration Form will not be processed without the completed Medical H<strong>is</strong><strong>to</strong>ry Form<br />

Reg<strong>is</strong>tration Form<br />

(Specialty <strong>Camps</strong> / Learning Institute / Sports Academy <strong>Camps</strong>)<br />

1


Reg<strong>is</strong>tration Form<br />

2<br />

(Specialty <strong>Camps</strong> / Learning Institute / Sports Academy <strong>Camps</strong>)<br />

Last Name (Please print.) First Name (Please print.)<br />

Date of Birth Grade (as of Sept. 2013) Age<br />

~ CHOOSE ONE FOR EACH SESSION ~<br />

Th<strong>is</strong> Reg<strong>is</strong>tration Form will not be processed without the completed Medical H<strong>is</strong><strong>to</strong>ry Form<br />

q Male q Female<br />

Specialty Choices Office Use Only Session 1 Session 2 Session 3 Session 4 Office Use Only<br />

______________________________________________________________________________________________________________________________<br />

Ac<strong>to</strong>rs Workshop 30031 30032 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Adventure Education 10111 10112 not in session<br />

______________________________________________________________________________________________________________________________<br />

Baseball 10021 10022 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Basketball 10031 10032 not in session<br />

______________________________________________________________________________________________________________________________<br />

Bowling 50011 50012 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Cheerleading 10091 10092 (Grades 2-5) not in session<br />

______________________________________________________________________________________________________________________________<br />

(6 <strong>we</strong>eks<br />

Counselor Apprentice Program<br />

______________________________________________________________________________________________________________________________<br />

only) N/A 10062 not in session<br />

Cub Camp 40010 40010<br />

______________________________________________________________________________________________________________________________<br />

Dance 30011 30012 not in session<br />

______________________________________________________________________________________________________________________________<br />

Fine Arts 20031 20032 not in session<br />

______________________________________________________________________________________________________________________________<br />

Flag Football 50001 50002 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Ga-ga Dodgeball 20091 20092 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Golf 10051 10052 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Kick-Start Athletics 10011 N/A (Grades 2-5) not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Marine Biology N/A 20072 not in session (Grades 6-9)<br />

not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

(Grades 6-9 must reg<strong>is</strong>ter<br />

Musical Theater<br />

______________________________________________________________________________________________________________________________<br />

for at least sessions 2&3) 30021 30022 not in session<br />

Science Education 20051 20052 not in session<br />

______________________________________________________________________________________________________________________________<br />

Soccer 10071 10072 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Tenn<strong>is</strong> 10081 10082 not in session<br />

______________________________________________________________________________________________________________________________<br />

Write-O-Rama 20061 20062 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

______________________________________________________________________________________________________________________________<br />

Learning Institute Choices Office Use Only Session 1 Session 2 Session 3 Session 4 Office Use Only<br />

Astronautics 10411 10412 not in session not in session (Grades 4-9) not in session<br />

______________________________________________________________________________________________________________________________<br />

Bioengineering/Forensic Science N/A 10152 not in session (Grades 6-9) not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Creative Computers 20011 N/A (Grades 2-5) (Grades 2-5) not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Fashion Design I 10311 10312 (Grades 4-9) not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Fashion Design Workshop 10431 10432 not in session (Grades 4-9) not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Gifted Camp 20021 N/A not in session<br />

______________________________________________________________________________________________________________________________<br />

Math Skills 10631 10632 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Reading/Writing Learning Clinic 20041 20042 not in session<br />

______________________________________________________________________________________________________________________________<br />

Robotics – Level 1 10281 10282 (Grades 4-9) not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Robotics Workshop 10211 10212 not in session (Grades 4-9) (Grades 6-9) not in session<br />

______________________________________________________________________________________________________________________________<br />

VG: 3-D Animation Studio 10261 10262 (Grades 4-9) (Grades 6-9) (Grades 6-9)<br />

______________________________________________________________________________________________________________________________<br />

not in session<br />

VGO: Starburst 10221 N/A (Grades 2 and 3) not in session (Grades 2 and 3) not in session<br />

______________________________________________________________________________________________________________________________<br />

VG1: Intro <strong>to</strong> Video Game Development 10141 10142 (Grades 4-9) (Grades 4-9) (Grades 4-9) not in session<br />

______________________________________________________________________________________________________________________________<br />

VG2: Video Game Programming N/A 10292 not in session (Grades 6-9) not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

VG3: Video Game Design Studio N/A 10242 (Grades 6-9) (Grades 6-9) (Grades 6-9) not in session<br />

______________________________________________________________________________________________________________________________<br />

Web Publ<strong>is</strong>hing N/A 30002 (Grades 6-9) (Grades 6-9) not in session not in session<br />

______________________________________________________________________________________________________________________________


Last Name (Please print.) First Name (Please print.)<br />

Date of Birth Grade (as of Sept. 2013) Age<br />

~ CHOOSE ONE FOR EACH SESSION ~<br />

______________________________________________________________________________________________________________________________<br />

Session 4 Office Use Only Session 1 Session 2 Session 3 Session 4 Office Use Only<br />

______________________________________________________________________________________________________________________________<br />

Overnight Camp (Must pick a session 4 90118 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

day program)<br />

Aquatic Camp 90101 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Car<strong>to</strong>oning Workshop 92000 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Recreation Camp 90111 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Video Mania Camp 93000 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Travel Camp 90107 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Sports Academy Choices Office Use Only Session 1 Session 2 Session 3 Session 4 Office Use Only<br />

______________________________________________________________________________________________________________________________<br />

Shannon Smith Girls Lacrosse 10000 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Chr<strong>is</strong>tine A. Nowierski Cheer 10008 not in session<br />

______________________________________________________________________________________________________________________________<br />

Fred Motley Pep Band 10010 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

<strong>Hofstra</strong> <strong>University</strong> Softball 10007 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Kelly Olsen Dance 10009 not in session<br />

______________________________________________________________________________________________________________________________<br />

Kr<strong>is</strong>ta Kilburn-Steveskey Girls Basketball 10004 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Kr<strong>is</strong>tina Hernandez Volleyball 09999 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

<strong>Hofstra</strong> <strong>University</strong> Boys Elite Basketball 10002 not in session<br />

______________________________________________________________________________________________________________________________<br />

John Russo Baseball 10001 not in session<br />

______________________________________________________________________________________________________________________________<br />

Richard Nuttall and Simmon Riddiough 10006<br />

not in session<br />

Soccer<br />

______________________________________________________________________________________________________________________________<br />

Rob Anspach Wrestling 10005 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Seth Tierney Boys Lacrosse 10003 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Other Office Use Only Session 1 Session 2 Session 3 Session 4 Office Use Only<br />

______________________________________________________________________________________________________________________________<br />

REACH Program 20023 N/A<br />

______________________________________________________________________________________________________________________________<br />

REACH Program for Teens N/A 20024 not in session<br />

______________________________________________________________________________________________________________________________<br />

Extended Hours Program 80000<br />

______________________________________________________________________________________________________________________________<br />

DISCOUNTS (Must be parent/guardian of camper.):<br />

5 <strong>Hofstra</strong> Alumni<br />

Year of Graduation Major and Degree<br />

Name at Time of Graduation<br />

5 <strong>Hofstra</strong> Full-Time Employee 5 Sibling 5 Group/Team<br />

5 Union (Company ID must accompany reg<strong>is</strong>tration form.)<br />

____________________________________________________<br />

Office Use Only<br />

Sub<strong>to</strong>tal: $<br />

____________________________________________________<br />

Application Fee:<br />

____________________________________________________<br />

Surcharge:<br />

____________________________________________________<br />

Grand Total:<br />

q Male q Female<br />

Th<strong>is</strong> Reg<strong>is</strong>tration Form will not be processed without the completed Medical H<strong>is</strong><strong>to</strong>ry Form<br />

$<br />

$<br />

$<br />

Reg<strong>is</strong>tration Form (Specialty <strong>Camps</strong> / Learning Institute / Sports Academy <strong>Camps</strong>)<br />

3


Reg<strong>is</strong>tration Form<br />

4<br />

(Specialty <strong>Camps</strong> / Learning Institute / Sports Academy <strong>Camps</strong>)<br />

<strong>Summer</strong> <strong>Camps</strong><br />

A choice <strong>that</strong> can change your child’s life!<br />

REGISTRATION<br />

By reg<strong>is</strong>tering my child(ren) <strong>to</strong> attend <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> 2013, I agree <strong>to</strong> the following terms as they apply.<br />

· Deposit: A check/credit card payment of $250 per session; nonrefundable deposit, must accompany th<strong>is</strong> reg<strong>is</strong>tration form. (Transportation and lunch<br />

are included in tuition.)<br />

· Payment in full <strong>is</strong> due May 1, 2013.<br />

· Full payment <strong>is</strong> required on all reg<strong>is</strong>trations received after May 1, 2013.<br />

· We accept MasterCard, V<strong>is</strong>a and American Express, cash <strong>is</strong> not accepted.<br />

· Please make checks payable <strong>to</strong> <strong>Hofstra</strong> <strong>University</strong>, and include your child’s name on check.<br />

· Extended Hours Program Tuition: $125 per session, in addition <strong>to</strong> the camp tuition ($50 for Session 4).<br />

DISCOUNTS:<br />

*Only one d<strong>is</strong>count per camper may be applied. D<strong>is</strong>counts may not be combined.<br />

· Sibling D<strong>is</strong>count: $50 off each additional child for Specialty and Learning Institute <strong>Camps</strong> (enrolled from same family) per two-<strong>we</strong>ek session;<br />

applicable for spring tuition rate only. Sibling D<strong>is</strong>count does NOT apply <strong>to</strong> Sports Academy <strong>Camps</strong> or Session 4.<br />

· <strong>Hofstra</strong> Alumni D<strong>is</strong>count: 15 percent for Specialty <strong>Camps</strong> and Learning Institute, 10 percent for Sports Academy <strong>Camps</strong>. (Alumnus must be parent of camper).<br />

· Union D<strong>is</strong>counts: 15 percent for Specialty <strong>Camps</strong> and Learning Institute, 10 percent for Sports Academy <strong>Camps</strong>. (Reg<strong>is</strong>tration must be accompanied by<br />

a current copy of a company pho<strong>to</strong> ID card. Union member must be parent/guardian of camper.)<br />

· <strong>Hofstra</strong> Full-Time Employee D<strong>is</strong>count: 25 percent. (Employee must be parent of camper.)<br />

· Group/Team D<strong>is</strong>count (five (5) or more campers): $75 d<strong>is</strong>count per camper, per session at the applicable tuition rate for sports academy camps only.<br />

· The Counselor Apprentice Program <strong>is</strong> available for six-<strong>we</strong>ek enrollment ONLY. Tuition for the full program <strong>is</strong> $2,500, plus the $50 application fee;<br />

no d<strong>is</strong>counts apply.<br />

REFUND POLICY<br />

· Tuition <strong>is</strong> refundable prior <strong>to</strong> May 1, 2013, less the deposit and application fee.<br />

· No refunds after May 1, 2013, for any reason, including illness, injury, personal, m<strong>is</strong>sed days, transportation delays, etc.<br />

· No refunds for surcharges after May 1, 2013.<br />

· Any cancellations must be received in writing.<br />

· It <strong>is</strong> unders<strong>to</strong>od <strong>that</strong> no credit will be given for camp closings, absences, family vacations, transportation delays or withdrawals.<br />

We reserve the right <strong>to</strong> cancel any reg<strong>is</strong>tration if fees are not paid in full by May 1, 2013.<br />

POLICIES AND PARENT/GUARDIAN CONTRACT<br />

By reg<strong>is</strong>tering my child(ren) <strong>to</strong> attend <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> 2013, I agree <strong>to</strong> the following terms as they apply.<br />

· Selected programs are subject <strong>to</strong> a surcharge.<br />

· We reserve the right <strong>to</strong> cancel th<strong>is</strong> reg<strong>is</strong>tration if fees and tuition are not paid in full by May 1, 2013.<br />

· It <strong>is</strong> unders<strong>to</strong>od <strong>that</strong> no credit will be given for camp closings, absences, illness and injuries, family vacations, transportation delays or withdrawals.<br />

· It <strong>is</strong> unders<strong>to</strong>od <strong>that</strong> all pho<strong>to</strong>graphy or videos taken at <strong>Hofstra</strong> may be used for promotional purposes or in other ventures directly relating <strong>to</strong> camp<br />

and I agree with the terms outlined in the Publicity Release; see <strong>we</strong>bsite for details.<br />

· Enrollment in <strong>Hofstra</strong> programs establ<strong>is</strong>hes perm<strong>is</strong>sion for a child <strong>to</strong> engage in all program activities except as noted by the examining physician on<br />

child’s Physical Examination Form submitted <strong>to</strong> the Camp Infirmary.<br />

· <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> <strong>is</strong> accredited by the American Camp Association.<br />

· Enrollment in <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> establ<strong>is</strong>hes perm<strong>is</strong>sion for a child <strong>to</strong> participate in the instructional/recreational swim program unless otherw<strong>is</strong>e<br />

noted by a physician.<br />

· I understand and acknowledge the r<strong>is</strong>ks related <strong>to</strong> my child’s participation in <strong>Summer</strong> <strong>Camps</strong> and hold <strong>Hofstra</strong> <strong>University</strong>, its direc<strong>to</strong>rs, officers, trustees,<br />

employees and volunteers harmless for any and all injury or loss associated with such participation.<br />

· Identifying information may be d<strong>is</strong>closed as required by insurance or other regulations.<br />

· Reg<strong>is</strong>trations received by phone will be confirmed by email with an attached reg<strong>is</strong>tration form which includes the parent/contract agreement. The<br />

parent/contract agreement must be signed and returned <strong>to</strong> the camp office in order <strong>to</strong> complete child’s reg<strong>is</strong>tration.<br />

· Please do not send your child with je<strong>we</strong>lry or any electronics (cell phones, Nintendo DS, IPod, Ipads, Ipod <strong>to</strong>uch, MP3 player, iPod player, Game Boy, etc.).<br />

Sneakers with “wheelies” are NOT allo<strong>we</strong>d at camp. <strong>Hofstra</strong> <strong>is</strong> not responsible for lost or s<strong>to</strong>len items.<br />

· I have read and agree <strong>to</strong> the above.<br />

_____________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________<br />

Parent/Guardian Signature ______________________________________________________________________________________________________________________ Date<br />

METHOD OF PAYMENT<br />

Deposit: A $250 per session (nonrefundable deposit); per camper <strong>is</strong> required <strong>to</strong> reg<strong>is</strong>ter.<br />

A confirmation/balance due statement will be sent once deposit <strong>is</strong> processed; full payment due May 1, 2013.<br />

Check or money order payable <strong>to</strong> <strong>Hofstra</strong> <strong>University</strong>: Check number ____________________________<br />

Payment amount _______________________________<br />

Credit Card: q V<strong>is</strong>a q MasterCard q American Express<br />

____________________________________________________________________________________________________________________________________ _______________________________________________________________<br />

Credit Card Number _______________________________________________________________________________________________________________________________________ Card Expiration Date<br />

____________________________________________________________________________________________________________________________________ _______________________________________________________________<br />

Card Holder’s Name (as it appears on credit card)<br />

____________________________________________________________________________________________________________________________________ _______________________________________________________________<br />

Billing address (If different than the camper’s mailing address)<br />

____________________________________________________________________________________________________________________________________ _______________________________________________________________<br />

Signature _________________________________________________________________________________________________________________________________________________________ Date<br />

<strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> complies with all Nassau County Health Department regulations. <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> <strong>is</strong> accredited by the American Camp Association.<br />

How <strong>to</strong> submit <strong>Summer</strong> Camp Reg<strong>is</strong>tration Form via mail or by fax: Complete reg<strong>is</strong>tration from in full and either fax <strong>to</strong> 516-463-6114 or mail <strong>to</strong>:<br />

<strong>Hofstra</strong> <strong>University</strong> 250 <strong>Hofstra</strong> <strong>University</strong> Hempstead, NY 11549-2500 Attn: <strong>Summer</strong> <strong>Camps</strong><br />

Th<strong>is</strong> Reg<strong>is</strong>tration Form will not be processed without the completed Medical H<strong>is</strong><strong>to</strong>ry Form


(Please print.)<br />

250 <strong>Hofstra</strong> <strong>University</strong> I Hempstead, NY 11549-2500 I Phone: 516-463-6961 I Fax: 516-463-4836 I Email: CE-CAMPS@hofstra.edu<br />

Website: hofstra.edu/camp I Twitter: @HU<strong>Summer</strong><strong>Camps</strong><br />

Last Name (Camper) First Name (Camper)<br />

Date of Birth Age Grade (as of Sept. 2013)<br />

q Male q Female<br />

Mailing Address (Street) City State ZIP<br />

Home Phone Number Parent Email (An email address <strong>is</strong> requested for all camp correspondence, bus pass, etc.)<br />

Name (Mother/Guardian) Work Phone (Mother/Guardian) Cell Phone (Mother/Guardian)<br />

Name (Father/Guardian) Work Phone (Father/Guardian) Cell Phone (Father/Guardian)<br />

Emergency Contact Name Emergency Contact Number Name(s) of sibling(s) who are reg<strong>is</strong>tering<br />

Do you require transportation? q Yes q No<br />

Area Pickup Location (if not getting door-<strong>to</strong>-door transportation)<br />

Office Use Only – Reg<strong>is</strong>tration Number:<br />

1) 2)<br />

Cross Streets<br />

~ CHOOSE ONE FOR EACH SESSION ~<br />

T-shirt size (Choose one.)<br />

Adult: q S q M q L q XL q XXL<br />

<strong>Hofstra</strong> and Nassau BOCES Office Use Only Session 1 Session 2 Session 3 Session 4 Office Use Only<br />

July 1-12 July 15-July 26 July 29-August 9 August 12-16<br />

______________________________________________________________________________________________________________________________<br />

Culinary Arts Academy (Grades 7-10) B5100 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Fashion Academy (Grades 7-10) B5110 not in session not in session<br />

______________________________________________________________________________________________________________________________________<br />

Careers in Veterinary Medicine<br />

B5200<br />

not in session not in session<br />

(Grades 7-10)<br />

______________________________________________________________________________________________________________________________<br />

Criminal Justice Academy (Grades 7-10) B5210 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Become Your Own Personal Trainer<br />

B5225 not in session not in session not in session<br />

(Grades 7-10)<br />

______________________________________________________________________________________________________________________________<br />

Aviation Academy (Grades 7-10) B5310 not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

Remotely Operated Vehicles (ROV) /<br />

Underwater Archaeology Program B5400 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

(Grades 5-10)<br />

Outdoor Adventures (Grades 5-9) B5500 not in session not in session not in session<br />

______________________________________________________________________________________________________________________________<br />

A Field Study in Marine Biology B5600 not in session not in session not in session<br />

(Grades 7-10)<br />

______________________________________________________________________________________________________________________________<br />

Th<strong>is</strong> Reg<strong>is</strong>tration Form will not be processed without the completed Medical H<strong>is</strong><strong>to</strong>ry Form.<br />

Total<br />

Reg<strong>is</strong>tration Form (<strong>Hofstra</strong> and Nassau BOCES)


Reg<strong>is</strong>tration Form<br />

(<strong>Hofstra</strong> and Nassau BOCES)<br />

<strong>Summer</strong> <strong>Camps</strong><br />

A choice <strong>that</strong> can change your child’s life!<br />

REGISTRATION<br />

By reg<strong>is</strong>tering my child(ren) <strong>to</strong> attend <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> 2013, I agree <strong>to</strong> the following terms as they apply.<br />

· Deposit: A check/credit card payment of $250 per session nonrefundable deposit must accompany th<strong>is</strong> reg<strong>is</strong>tration form. (Transportation and lunch<br />

are included in tuition.)<br />

· Payment in full <strong>is</strong> due May 1, 2013.<br />

· Full payment <strong>is</strong> required on all reg<strong>is</strong>trations received after May 1, 2013.<br />

· We accept MasterCard, V<strong>is</strong>a and American Express; cash <strong>is</strong> not accepted.<br />

· Please make checks payable <strong>to</strong> <strong>Hofstra</strong> <strong>University</strong>, and include your child’s name on check.<br />

· Extended Hours Program Tuition: $125 per session, in addition <strong>to</strong> the camp tuition ($50 for Session 4).<br />

REFUND POLICY<br />

· Tuition <strong>is</strong> refundable prior <strong>to</strong> May 1, 2013, less the deposit.<br />

· No refunds after May 1, 2013, for any reason, including illness, injury, personal, m<strong>is</strong>sed days, transportation delays, etc.<br />

· Any cancellations must be received in writing.<br />

· It <strong>is</strong> unders<strong>to</strong>od <strong>that</strong> no credit will be given for camp closings, absences, family vacations, transportation delays or withdrawals.<br />

· We reserve the right <strong>to</strong> cancel any reg<strong>is</strong>tration if fees are not paid in full by May 1, 2013.<br />

POLICIES AND PARENT/GUARDIAN CONTRACT<br />

By reg<strong>is</strong>tering my child(ren) <strong>to</strong> attend <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> 2013, I agree <strong>to</strong> the following terms as they apply.<br />

· We reserve the right <strong>to</strong> cancel th<strong>is</strong> reg<strong>is</strong>tration if fees and tuition are not paid in full by May 1, 2013.<br />

· It <strong>is</strong> unders<strong>to</strong>od <strong>that</strong> no credit will be given for camp closings, absences, illness and injuries, family vacations, transportation delays or withdrawals.<br />

· It <strong>is</strong> unders<strong>to</strong>od <strong>that</strong> all pho<strong>to</strong>graphy or videos taken at <strong>Hofstra</strong> may be used for promotional purposes or in other ventures directly relating <strong>to</strong> camp<br />

and I agree with the terms outlined in the Publicity Release; see <strong>we</strong>bsite for details.<br />

· Enrollment in <strong>Hofstra</strong> programs establ<strong>is</strong>hes perm<strong>is</strong>sion for a child <strong>to</strong> engage in all program activities except as noted by the examining physician on<br />

child’s Physical Examination Form submitted <strong>to</strong> the Camp Infirmary.<br />

· <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> <strong>is</strong> accredited by the American Camp Association.<br />

· I understand and acknowledge the r<strong>is</strong>ks related <strong>to</strong> my child’s participation in <strong>Summer</strong> <strong>Camps</strong> and hold <strong>Hofstra</strong> <strong>University</strong>, its direc<strong>to</strong>rs, officers, trustees,<br />

employees and volunteers harmless for any and all injury or loss associated with such participation.<br />

· Identifying information may be d<strong>is</strong>closed as required by insurance or other regulations.<br />

· Reg<strong>is</strong>trations received by phone will be confirmed by email with an attached reg<strong>is</strong>tration form which includes the parent/contract agreement. The<br />

parent/contract agreement must be signed and returned <strong>to</strong> the camp office in order <strong>to</strong> complete child’s reg<strong>is</strong>tration.<br />

· Please do not send your child with je<strong>we</strong>lry or any electronics (cell phones, Nintendo DS, IPod, Ipads, Ipod <strong>to</strong>uch, MP3 player, iPod player, Game Boy, etc.).<br />

Sneakers with “wheelies” are NOT allo<strong>we</strong>d at camp. <strong>Hofstra</strong> <strong>is</strong> not responsible for lost or s<strong>to</strong>len items.<br />

· I have read and agree <strong>to</strong> the above.<br />

_____________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________<br />

Parent/Guardian Signature ______________________________________________________________________________________________________________________ Date<br />

METHOD OF PAYMENT<br />

Deposit: A $250 per session (nonrefundable deposit) per camper <strong>is</strong> required <strong>to</strong> reg<strong>is</strong>ter.<br />

A confirmation/balance due statement will be sent once deposit <strong>is</strong> processed; full payment due May 1, 2013.<br />

Check or money order payable <strong>to</strong> <strong>Hofstra</strong> <strong>University</strong>: Check number ____________________________<br />

Payment amount _______________________________<br />

Credit Card: q V<strong>is</strong>a q MasterCard q American Express<br />

____________________________________________________________________________________________________________________________________ _______________________________________________________________<br />

Credit Card Number _______________________________________________________________________________________________________________________________________ Card Expiration Date<br />

__________________________________________________________________________________________________________________________________________________________________________________________________________<br />

Card Holder’s Name (as it appears on credit card)<br />

__________________________________________________________________________________________________________________________________________________________________________________________________________<br />

Billing Address (If different than the camper’s mailing address)<br />

____________________________________________________________________________________________________________________________________ _______________________________________________________________<br />

Signature _________________________________________________________________________________________________________________________________________________________ Date<br />

<strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> complies with all Nassau County Health Department regulations. <strong>Hofstra</strong> <strong>Summer</strong> <strong>Camps</strong> <strong>is</strong> accredited by the American Camp Association.<br />

How <strong>to</strong> submit <strong>Summer</strong> Camp Reg<strong>is</strong>tration Form via mail or by fax: Complete reg<strong>is</strong>tration form in full and either fax <strong>to</strong> 516-463-4836 or mail <strong>to</strong><br />

<strong>Hofstra</strong> <strong>University</strong>, 250 <strong>Hofstra</strong> <strong>University</strong>, Hempstead, NY 11549-2500 Attn: Seth Liebstein.<br />

Th<strong>is</strong> Reg<strong>is</strong>tration Form will not be processed without the completed Medical H<strong>is</strong><strong>to</strong>ry Form.


MAILING ADDRESS<br />

<strong>Hofstra</strong> <strong>University</strong> <strong>Summer</strong> <strong>Camps</strong><br />

250 <strong>Hofstra</strong> <strong>University</strong><br />

Hempstead, NY 11549-2500<br />

Phone: 516-463-2267<br />

Fax: 516-463-6114<br />

Name______________________________________________________________________________________________________________________ Birth Date ________/ ________/_______________ Sex_____________ Age __________________<br />

Last First M.I.<br />

Parent or Guardian (or Spouse) _____________________________________________________________________________________________________________Phone (_____________)_______________________________________<br />

Home Address ____________________________________________________________________________________________________________________________________________________________________________________________________________<br />

Street and Number City State ZIP Code<br />

Business Address _____________________________________________________________________________________________________________________________________Phone (_____________)_______________________________________<br />

Street and Number City State ZIP Code<br />

Second Parent or Guardian: ____________________________________________________________________________________________________________________________________________________________________________________<br />

Home Address _________________________________________________________________________________________________________________________________________Phone (_____________)_______________________________________<br />

Street and Number City State ZIP Code<br />

If not available in an emergency, notify: _______________________________________________________________________________________________Phone (_____________)_______________________________________<br />

Address ______________________________________________________________________________________________________________________________________________________________________________________________________________________<br />

Street and Number City State ZIP Code<br />

Health H<strong>is</strong><strong>to</strong>ry:<br />

(Check and give approximate dates.)<br />

6 Frequent Ear Infections _____________________<br />

6 Heart Defect/D<strong>is</strong>ease _____________________<br />

6 Convulsions/Epilepsy _____________________<br />

6 Diabetes _____________________<br />

6 Bleeding/Clotting D<strong>is</strong>order _____________________<br />

6 Hypertension _____________________<br />

6 Psychiatric Treatment _____________________<br />

6 Mononucleos<strong>is</strong> _____________________<br />

6 Asthma _____________________<br />

6 Allergies _____________________<br />

Has th<strong>is</strong> camper ever required any psychiatric counseling or hospitalization?<br />

________________________________________________________________________________________________________________________<br />

Operations or serious injuries (dates): ___________________________________________________________<br />

________________________________________________________________________________________________________________________<br />

D<strong>is</strong>ability or chronic or recurring illness: ________________________________________________________<br />

________________________________________________________________________________________________________________________<br />

Any specific activities <strong>to</strong> be encouraged or limited by physician’s advice:<br />

________________________________________________________________________________________________________________________<br />

Other d<strong>is</strong>eases or details of above: _______________________________________________________________<br />

________________________________________________________________________________________________________________________<br />

________________________________________________________________________________________________________________________<br />

IMPORTANT — BOX A OR B MUST BE COMPLETED FOR CAMPER’S ATTENDANCE.<br />

PERMISSION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE:<br />

I hereby give perm<strong>is</strong>sion <strong>to</strong> the medical personnel selected by the camp direc<strong>to</strong>r <strong>to</strong> order X-rays, routine tests, and treatment; <strong>to</strong> release<br />

any records necessary for insurance purposes; and <strong>to</strong> provide or arrange necessary related transportation for me and/or my child. In the<br />

event I cannot be reached in an emergency, I hereby give perm<strong>is</strong>sion <strong>to</strong> the physician selected by the camp direc<strong>to</strong>r <strong>to</strong> secure and admin<strong>is</strong>ter<br />

treatment, including hospitalization, for the person named above. Th<strong>is</strong> completed form may be pho<strong>to</strong>copied for off-campus trips.<br />

Signature of parent or guardian or adult camper/staffer ______________________________________________________________________________________________________________________________________<br />

I do not w<strong>is</strong>h <strong>to</strong> give the camp perm<strong>is</strong>sion <strong>to</strong> give emergency care if I cannot be reached.<br />

Date__________________________<br />

To be filled in by parents/guardians of minors or by adult campers/staff members themselves.<br />

Your child’s reg<strong>is</strong>tration will not be processed until the medical h<strong>is</strong><strong>to</strong>ry <strong>is</strong> entirely completed<br />

and signed, do not leave any lines blank, enter N/A if not applicable.<br />

A<br />

B<br />

MEDICAL HISTORY FORM<br />

Family Medical H<strong>is</strong><strong>to</strong>ry<br />

6 Premature death related <strong>to</strong> cardiovascular d<strong>is</strong>ease<br />

6 D<strong>is</strong>ability from cardiovascular d<strong>is</strong>ease at age

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