day-time only camp application form - International Programs

Camp Bear International Day Program
Summer 2010
Dates:
Program Dates: Week 1 June 28 – July 2
Week 2 July 5 – July 9
Week 3 July 12 – July 16
Week 4 July 19 – July 23
Week 5 July 26 – July 30
Camp Fees include English Language Institute classes, Camp Bear classes, recreation activities,
Camp Bear t-shirt, free buffet lunch on Tuesdays, entrance to swimming pool on Fridays
Price per week MSU* Price per week
1 week $225.00 $215.00
2 – 3 week $215.00 $205.00
4 – 5 week $210.00 $190.00
*Parent/guardian who is a current MSU student/staff/faculty is eligible for the MSU discount
prices.
SCHEDULE:
8:45 Drop-off at
9:00-11:30 English Language Institute Classes in Madison Hall 202
11:30-12:00 Lunch with Camp Bear at Plaster Student Union
12:00-12:20 Recreation/Activities
12:20-12:30 Assembly/To classes
12:30-2:15 Camp Bear Classes
2:15-2:30 Snack
2:30-4:30 Recreation/Activities with Camp Bear group
4:30-5:00 Supervised group play/Pick-up at Plaster Student Union
OTHER IMPORTANT INFORMATION:
• Campers should bring a sack lunch or money to buy lunch at Plaster Student Union.
All campers get a free buffet lunch on Tuesdays.
• Campers should also wear their Camp Bear t-shirt on Tuesdays.
• Thursdays are Theme Days, so camper will be asked to wear special clothes on
Thursdays. They will find out the week’s theme on Monday.
• An afternoon snack is provided free for all campers every day.
• On Fridays, campers will go swimming in the afternoon, so they need to bring a
swimsuit and towel.
• Campers should wear comfortable summer clothing and tennis shoes every day.
Full payment for this program is due by June 25, 2010. No refunds will be given after July
2.

REGISTRATION INFORMATION:
Please choose (1) How many weeks your child is attending and (2) Choice of week.
NUMBER OF WEEK PRICE PER WEEK
□ 1 WEEK $225.00 (215.00)
□ 2 WEEK – 3 WEEK $215.00 (205.00)
□ 4 WEEK – 5 WEEK $210.00 (190.00)
CHOICE OF WEEK
□ JUNE 28 WEEK
□ JULY 5 WEEK
□ JULY 12 WEEK
□ JULY 19 WEEK
□ JULY 26 WEEK
CAMPER’S PERSONAL INFORMATION:
Family Name: Middle Name: Given Name:
Address: City: State: Postal Code:
Home Telephone:
Date of Birth:
____/____/_____
Month Day Year
Country of Birth:
Email:
Gender:
Male______
Female______
Country of Citizenship:
Youth Small ____
Youth Medium___
Youth Large_____
T-Shirt Size (Check one)
Adult Small _____
Adult Medium___
Adult Large _____
PARENTS INFORMATION:
Mother’s Name: Middle Name: Given Name:
Address (if different than
above):
Home Telephone:
Country of Birth:
City: State: Postal Code:
Email:
Country of Citizenship:
Father’s Name: Middle Name: Given Name:
Address (if different than
above):
City:
State:
Home Telephone: Email: Postal Code:

Country of Birth:
Country of Citizenship:
ACADEMIC INFORMATION:
Name of School You are Currently Attending:
Have you taken English classes before?
Yes_______ No______
Bad _______
How would you rate your English ability?
Good ☺______
Grade in School:
If yes, for how many years?_______
Not bad ______
Great! ☺☺_______
Have you ever traveled to another country?
Please tell us about your hobbies:
If so, where?
HEALTH INFORMATION:
Allergies (list all foods, asthma, hay fever, bee stings, other)
Do you have any medical conditions that require regular medication?
Do you have any restrictions of activity for medical reasons?

Parent Authorization:
I know that every reasonable and customary precaution will be taken to assure the safety of everyone. I
waive all claims in the event of an accident or injury absolving the Camp Bear International Program
and all individuals thereof, from responsibility. In cases of illness of my son/daughter, I authorize Camp
Bear International, through the appropriate staff, to seek medical treatment at my expense. I give
permission to Camp Bear International to use photos/video taken of my son/daughter at the camp for
promotional use only. I have read the policies and agree to cooperate.
Parent Signature ________________________________________ Date ____________________
PAYMENT (refer to weekly Camp Fee Chart on first page):
Total Payment: Weekly Fee $____________X # of Week = Total Amount Due $ ._
Types of Payment (select one)
□ I or my agent will contact the English Language Institute with credit card information.
□ I or my agent will mail a money order for the amount in the US dollar.
*$50 non-refundable deposit is required at the time of registration. This will be applied to the balance of
the total amount due.
Mailing Address:
English Language Institute
Camp Bear International
301 S. Jefferson Avenue
Springfield, MO 65806
Fax Number: 1- 417-836-4784
Phone Number: 1-417-836-6540
Cancellation/Refund Policy
Individual cancellations must be received in writing no later than 7 days prior to the start of each week of classes to ensure a
full refund minus a 15% processing fee. Transfers from one week will be allowed without penalty as long as space is
available. Cancellations after the 7-day deadline will garner no refunds. There will be no refund for students who voluntarily
withdraw for any reason before the end of the class week or who are asked to leave for disciplinary reasons. Missouri State
University reserves the right to cancel classes