2015 DSSV Palo Alto summercamp registration form
From June 15th until June 19th 2015
Sign in to Google to save your progress. Learn more
Registration
I'd hereby like to register my child/children for the 2015 DSSV summercamp in Palo Alto. Name, age and grade-level of my child/children will be filled in at the emergency information section of this form.
Pick-up time from my child/children will be *
3 PM
5 PM
Monday June 15th
Tuesday June 16th
Wednesday June 17th
Thursday June 18th
Friday June 19th
Initials *
Payment
The fee for the summer-camp is $395 per student.

Registration needs to be received by the DSSV on or before May 15th, 2015. Payment is due at time of registration.

The Dutch School Silicon Valley offers the following payment options. Please include your children’s names with your payment.

1. Check: All checks need to be made payable to “Dutch School Silicon Valley” or “DSSV”.
Please send the checks to:

Dutch School Silicon Valley
P.O. Box 51826
Palo Alto, CA 94303

2. Automated Bank Transfer (ACH):
Beneficiary: Dutch School Silicon Valley
Beneficiary account number: 200044899
Beneficiary bank routing number: 321171184
Beneficiary bank: Citibank

Cancellation by parent/student

Any cancellation received by the DSSV:
- on or before April 15 will receive a full refund ($395).
- between April 16 and May 15 will receive a refund of $200
- after May 15 will NOT receive any refund.

Cancellation by DSSV

A minimum total amount of 9 children needs to register for the summer-camp to continue as planned.
The DSSV holds the right to cancel the summer-camp when the required amount of registrations isn’t received by May 16. A full refund of $395 will be issued in case of such cancellation.

If juf Chantal van Schooten and juf Tessa de Boer fall ill and it is known beforehand that they can’t lead the summer-camp for the entire week, the summer-camp will be cancelled and the $395 will be refunded.

Initials *
Permission to Use Photographs
During the course of the DSSV summercamp, the Dutch School Silicon Valley may wish to place photographs of the summercamp activities on the password protected DSSVfotos-onedrive-website (http://onedrive.live.com), in the DSSV newspaper of October 2015, on a flyer to advertise for a 2016 DSSV summercamp or on the DSSV Facebook page. The password of the dssvfotos-onedrive change yearly (so only current DSSV families, staff and board members have access to it) . The school newspaper of October 2015 will only be emailed out to then current DSSV families, staff and board members as well. The flyer to advertise for a 2016 DSSV summercamp and the DSSV Facebook page are public and not password protected.

In accordance with school policy, no names of individuals will be released with any photographs.

We consent to the use of photos of my child/children/other family members taken during the 2015 DSSV summercamp *
Yes, we consent
No, we do NOT consent
on the password protected DSSVfotos-onedrive-website
in the DSSV newspaper of October 2015
on the flyer advertising the 2016 DSSV summercamp (used publicly)
on the DSSV facebook (public)
Initials *
Waive and release
The undersigned (the “Signer”), being the parent(s) and/or legal guardian(s) of the minor child(ren) (the “Child”) named at the emergency section below , for valuable and sufficient consideration, receipt of which is hereby acknowledged, on behalf of themselves and the Child do hereby knowingly and intentionally fully and irrevocably release, to the full extent permitted by California law, the Dutch School Silicon Valley (the “School”), and its board members, directors, officers, sponsors, administrators, staff (a.o. teachers and teaching assistents), employees, volunteers and agents, from any and all claims or liability, known or unknown, of any kind whatsoever, which may now exist, or at any time in the future arise, with regard to any matters relating, directly or indirectly, to the Child’s enrollment or attendance at the DSSV summercamp of the School, or to the Signer’s or the Child’s participation in any activities directly or indirectly related to, or sponsored or sanctioned by, the School, regardless of whether or not said activities occur on School premises or elsewhere. By our initials below and by our signatures at the end of this form, we knowingly waive and release any and all legal claims that we or the child(ren) may now or in the future have against the School, or anyone connected with it.
Initials *
Emergency information
Last name *
Street address *
City *
Zipcode *
First name child 1 *
Age child 1 *
Date of birth child 1 *
(month/day/year)
Grade (as of Sept 2015) child 1 *
Allergies (including the use and availability of epi-pens) / other important medical information child 1 *
Learning challenges / disabilities / handicaps child 1 *
IEP (Individual Education Plan) child 1 *
First name child 2
Age child 2
Date of birth child 2
(month/day/year)
Grade (as of Sept 2015) child 2
Allergies (including the use and availability of epi-pens) / other important medical information child 2
Learning challenges / disabilities / handicaps child 2
IEP (Individual Education Plan) child 2
Clear selection
First name child 3
Age child 3
Date of birth child 3
(month/day/year)
Grade (as of Sept 2015) child 3
Allergies (including the use and availability of epi-pens) / other important medical information child 3
Learning challenges / disabilities / handicaps child 3
IEP (Individual Education Plan) child 3
Clear selection
In case of a major emergency your child can only be released to :
First and last name of father (or male guardian) *
Address, city and zipcode of father (or male guardian) *
(if different from above - otherwise fill in same as above)
Daytime phonenumber of father (or male guardian) *
Cellphone number of father (or male guardian) *
Emailaddress of father (or male guardian) *
First and last name of mother (or female guardian) *
Address, city and zipcode of mother (or female guardian) *
(if different from above - otherwise fill in same as above)
Daytime phonenumber of mother (or female guardian) *
Cellphone number of mother (or female guardian) *
Emailaddress of mother (of female guardian) *
Names & phone-numbers of others that can pick up your child/children in case of an emergency *
Health care provider of your child/children *
Medical ID number of child 1 *
Medical ID number of child 2
Medical ID number of child 3
My child / my children have received all vaccines (or immunizations) obligated for his/her/their age/ages *
At all times the Dutch School Silicon Valley (the “School”), and its board members, directors, officers, administrators, staff (a.o. teachers and teaching assistants), employees, volunteers and agents,  are authorized to take any measures necessary for the protection of my child(ren) during the hours of the 2015 DSSV summercamp.
Initials *
To the best of our knowledge, all the information filled in on this registration form is true and complete. We have read the requirements and are fully committed to complying with them. We understand that payment of the required fees must be made by the payment deadlines outlined. Our signatures below affirm all of the above.
Signature of father *
Signature of mother *
Filling in this form is done at your own risk.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms