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2012 Camps
for students entering grades 4 to 9

Mission to Mars

CSI: Crime Scene Investigators

World of Energy

Magic of Harry Potter

Registration Form for Summer 2012

By submitting this form with the necessary information you are acknowledging your acceptance of the following releases:

Field Trip Release:

My child has permission to leave the Nazareth College of Rochester Campus for the purpose of attending field trips with the STC Science Camp Staff. Field trips are currently being organized and that I will be notified of the specific dates, times and locations of various field trips at the beginning of each camp session.

Photography/Video Release

I authorize the STC Science camp and Nazareth College of Rochester to have, take, and use without payment any photographs, slides, or videotapes of my child, as may be needed for public relations purposes, marketing/advertising purposes or internal training purposes.

This form also signifies acceptance by both the student and guardians of the Summer Camp's Code of Conduct.

First Name:	Last Name:
Address:	City:
State:	Zip Code:
Birth Date:	Gender: Male Female
School Name:	Science Teacher's Name:
Student's Grade in Fall:	T-Shirt Size:
Mother/Guardian's Name:	Home Phone:
Cell Phone:	Work Phone:
Father/Guardian's Name:	Home Phone:
Cell Phone:	Work Phone:
Emergency Contact:	Contact's Phone:
Physician's Name:	Physician's Phone:
Primary E-mail Address:

Medical Info:

Camp Choice: July 2-6 (No July 4): Energy @ Nazareth
July 9-13: Mars @ Nazareth
July 16-20: CSI @ Nazareth
July 23-27: Magic @ Nazareth

Fees for Summer 2012 are as follow s:

$295 for one camp
Multiple camp discount: deduct $25 per camp
- Two or more campers per family or two or more campers per child

If paying by check, make check payable to Nazareth College of Rocheste r and mail to: 4245 East Ave., Rochester, NY 14618. If paying by credit, please remember the amount due. You will be redirected to a page where you can pay following the submission of this form. Or, click HERE to go directly to pay by credit card through Nazareth College. Thank you.

Payment Method: Credit Card Check

Amount Due: