WinterCamp24-25

Winter Camp 24-25 Registration

Boston Youth Education & Counseling Winter Camp 24-25 Registration

Step 1 of 11 – Summer Camp Registration 2023

Youth Boys Winter Camp / December 20- December 26 / $650

Student Information

Student Name(Required)

First Last

Student Birth Date(Required)

MM slash DD slash YYYY

Select Region(Required)

Student Gender(Required)

Male

Student Grade in December 2024(Required)

Student Phone(Required)

Student Email(Required)

How many boy siblings will you register to this camp(Required)

Does the student have a sister attending a girls camps?(Required)

Yes

Primary Address(Required)

Street Address Address Line 2 City State ZIP Code

Sibling 1 Information

Sibling 1 Name(Required)

First Last

Sibling 1 Birth Date(Required)

MM slash DD slash YYYY

Sibling 1 Gender(Required)

Male

Sibling 1 Grade in December 2024(Required)

Sibling 1 Phone(Required)

Sibling 1 Email(Required)

Sibling 2 Information

Sibling 2 Name(Required)

First Last

Sibling 2 Birth Date(Required)

MM slash DD slash YYYY

Sibling 2 Gender(Required)

Male

Sibling 2 Grade in December 2024(Required)

Sibling 2 Phone(Required)

Sibling 2 Email(Required)

Parent / Guardian Information

Parent / Guardian Name(Required)

First Last

Parent / Guardian Phone(Required)

Parent / Guardian Email(Required)

Emergency Contact Information

Please list a contact that is not listed on this form, to be used if Parent / Guardian cannot be reached

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Relationship to Student(Required)

Physician Info

Do you have a physician(Required)

Physician Name(Required)

First Last

Physician Phone(Required)

Health info

Is there any special medical or dietary needs for Student(1)(Required)

Please list any medication the student needs, any allergies that you want us to be aware of and any dietary restriction that we would have to let our kitchen staff know.

Please list any medication the student needs, any allergies that you want us to be aware of and any dietary restriction that we would have to let our kitchen staff know. Student(1)(Required)

Is there any special medical or dietary needs for Student(2)(Required)

Please list any medication the student needs, any allergies that you want us to be aware of and any dietary restriction that we would have to let our kitchen staff know.

Please list any medication the student needs, any allergies that you want us to be aware of and any dietary restriction that we would have to let our kitchen staff know. Student(2)(Required)

Is there any special medical or dietary needs for Student(3)(Required)

Please list any medication the student needs, any allergies that you want us to be aware of and any dietary restriction that we would have to let our kitchen staff know.

Please list any medication the student needs, any allergies that you want us to be aware of and any dietary restriction that we would have to let our kitchen staff know. Student(3)(Required)

Consent

Emergency Consent(Required)

I have read and I agree to the policy.

“I understand that in the event of an emergency affecting my child while participating in Boston Education and Counseling program, a designated employee of Boston Education and Counseling will contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated or hospitalized by a licensed physician or hospital selected by Boston Education and Counseling.”

Camp Consent(Required)

I have read and I agree to the policy.

“By Submitting the form, I acknowledge the contagious nature of the Coronavirus/COVID-19. I further acknowledge that Boston Education and Counseling has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Boston Education and Counseling cannot guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to mentors, administration, and fellow participants. I voluntarily seek services provided by Boston Education and Counseling and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I attest that:
* I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days of the meeting day.
* I have not traveled to a highly impacted area within UNITED STATES in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/COVID-19 and not yet cleared as non-contagious by state or local public health authorities.
* I am following all government recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

I hereby release and agree to hold Boston Education and Counseling harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Boston Education and Counseling. I understand that this release discharges Boston Education and Counseling from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, drawn, medical treatment, or property damage that may arise from, or in connection to, any services received from Boston Education and Counseling. This liability waiver and release extends to the salon together with all owners, partners, and employees. Assumption of Risk and Waiver of Liability: In consideration of the above, I assume all risks associated with the preparation of food products supplied under this Agreement, including matters of health and safety associated thereof. I do hereby release, waiver, discharge, and covenant not to sue Boston Education and Counseling, and their respective Trustees, officers, employees, students and agents from liability from any and all claims including the negligence of said organizations and their respective Trustees, officers, employees and agents, resulting in personal injury, accident, or illness, including death and property loss arising from any and all food products provided under this Agreement. By registering to the Summer Camp hosted by Boston Education and Counseling.
I also consent to and acknowledge that I may be photographed/recorded at all times before, during, and after the event by the Boston Education and Counseling staff for promotional and inter-organizational purposes.”

Transportation

Transportation Consent(Required)

I understand that I am responsible of my children’s transportation.

Payment

For inquiries regarding scholarships, please email Finance@bostoneducation.us

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High School – Boys / December 20 – 26 / $….

Winter Camp – Boys(Required)

Price:

Winter Camp – Boys (Sibling Discount)(Required)

Price:

Winter Camp – Boys (Sibling Discount -sister org)(Required)

Price:

Winter Camp – Boys 2 (Sibling Discount)(Required)

Price:

Winter Camp – Boys 3 (Sibling Discount)(Required)

Price:

Coupon

Total

Payment Method

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

Winter Camp 24-25 Registration

Youth Boys Winter Camp / December 20- December 26 / $650

Student Information

Sibling 1 Information

Sibling 2 Information

Parent / Guardian Information

Emergency Contact Information

Physician Info

Health info

Consent

Transportation

Payment

High School – Boys / December 20 – 26 / $….

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