 Rocket Science 2012Tuesday, August 14th – Friday, August 17th, 9:00AM - 3:00PM
Children Entering Grades 1-6
$175pp (Pre-payment Required)
Rocket Science is a blast for any junior rocketeer! In the morning, our space scientists will learn about rocket propulsion by building compressed air rockets and rockets that blast off by chemical reactions! As flight engineers, kids will travel to infinity and beyond while they investigate how rockets get off the ground and soar to the heavens. During the week, kids will build an ultra-cool rocket, and launch on Friday (safety permitting).
In the afternoon, we'll learn all about the science of flight, and investigate how things fly. We'll travel across the solar system and learn about the rocky planets and the gas giants. We'll learn why what goes up must come down. Rocket Science with Wicked Cool For Kids will be out of this world!
REGISTRATION FORM
Camper's Name______________________________________________________Age_______ M / F
Date of Birth__________________________ Grade(fall 2012)_____
Address___________________________________________________________________________
PARENT / GUARDIAN:(Please Print) ______________________________________________________
Email (print)_________________________________________________________________
Phone# (HM)______________________ (WK)_______________________(CELL) ________________
Address (If Different) __________________________________________________________________
PICK-UP LIST: ONLY names listed on this form will be allowed to pick up your child:
Name_______________________________________________Relationship_______________________
Name_______________________________________________Relationship_______________________
Name_______________________________________________Relationship_______________________
Name_______________________________________________Relationship_______________________
ALTERNATE EMERGENCY CONTACT:
Name______________________________________________Relationship________________________
Address___________________________________________________ Phone_____________________
PERMISSION / AGREE TO HOLD HARMLESS:
I hereby give permission for my child to participate in the Wicked Cool For Kids Rocket Science Program with the Hopkinton Recreation Department. Participation in the Wicked Cool For Kids Rocket Science Program may involve risk of injury, which may include, but is not limited to falls, sprains, bruises, insect bites, torn muscles, broken bones, eye & head injuries, and/or death. As a parent or guardian, I attest and verify that I have full knowledge of all risks involved and that my child is physically fit to participate in the Wicked Cool For Kids Rocket Science Program. I hereby for myself, my heirs, executors, and administrators waive and release all rights and
claims against the Town of Hopkinton and Wicked Cool For Kids Rocket Science Program, its officers, agents, employees, and volunteers, except in the case of their sole negligence, from all losses, injury, damages, fees, and other expenses arising out of or in connection with participation. In addition, I give my permission for my child to be treated by qualified medical personnel in the event that I cannot be reached at the phone numbers provided above.
PARENT SIGNATURE_____________________________________________________DATE ___________________ PRINT NAME: ____________________________________
CAMPER HEALTH RECORD
The following information is to be completed by the parent. It will be held confidential and will be only used to benefit your child. PLEASE PRINT CLEARLY, SIGN and DATE.
Are there any significant findings that could influence the child’s adaptations to a child care/camp setting? (.i.e., physical handicap, sensory problems or loss, developmental irregularities)
_____________________________________________________________________________________
_____________________________________________________________________________________
Are there any chronic illnesses that may require regular medication, or other precautions needed
with regard to allergies to food or medications?
_____________________________________________________________________________________
_____________________________________________________________________________________
List any diet modifications or special medications we should know about:
_____________________________________________________________________________________
_____________________________________________________________________________________
Are there any hospitalizations, operations, special test or reoccurring illnesses of which the camp staff should be aware of?
_____________________________________________________________________________________
_____________________________________________________________________________________
PHYSICIAN NAME________________________________________________ PHONE_______________
HOSPITAL/ADDRESS ____________________________________________________________________
MEDICAL INSURANCE COVERAGE? (YES /NO)
COMPANY NAME_______________________________ ID#___________________________
In case of emergency, I hereby give permission to the camp staff and medical personnel selected by the staff, in my absence, to act as my agent in securing proper medical treatment for my child as named above, including hospitalization, routine tests, X-rays and other medical treatment. Every possible effort will be made to contact parents in the event of an emergency.
PARENT SIGNATURE____________________________________ DATE_________________
Photo Release
I hereby grant the Town of Hopkinton permission to use my child’s photograph, video picture, and/or other digital reproduction of him/her or other reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the Internet or other Recreation Department materials.
Please Check: ___Accept ___Decline Parent’s signature _________________________________
Please Mail Registration form and check to:
Hopkinton Recreation Department
330 Main Street
Hopkinton, NH 03229
(Registration may also be dropped off at the Town Hall or Slusser Senior Center)
| 
