CAMPER INFORMATION

Name of Participant: First: MI: Last:

Participant will attend: Session I: July 21 - July 25, 2008 ($350) Session II: July 28 - August 1, 2008 ($350)

Birth Date (PLEASE SELECT): Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 1992 1993 1994 1995 1996 1997 Gender: male female Age as of July 2008: If applicable, list the year(s) of previous Alexandria Archaeology Summer Camp session(s) you have attended

CONTACT INFORMATION

Street         Apt# :      City:        State:   --- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY     Zip Code  Home Telephone:  E-mail Address:

PARENT/GUARDIAN INFORMATION

Responsible Party's Driver's License Number: State:   --- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Mother's Name:    Mother's Work # :

Father's Name:     Father's Work # :

Guardian's Name:    Guardian's Work # :

If parent or guardian cannot be reached, please contact: 1.     Work # : 2.     Work # :

MEDICAL INFORMATION

Name of Insurance or Health Care Program in which participant is enrolled: Policy # : Physician's Name: Medication Participant is taking: Medication is treatment for: Physical Restriction: Allergies: Learning Problems: Date of Tetanus shot: (all participants are required to have had a tetanus shot within the last 10 years) Medical Insurance: The City does not provide medical insurance for participants. In the event of illness or injury requiring treatment, hospitalization, and/or surgery, the family medical insurance must be used.

PERMISSIONS

In consideration of the City of Alexandria, Office of Historic Alexandria, Alexandria Archaeology conducting various programs and allowing to participate in such programs, the undersigned, realizing the risk of injury attendant to such programs, does hereby release and forever discharge the City of Alexandria and the City's Office of Historic Alexandria, Alexandria Archaeology and its officers, agents, and employees from any and all actions, claims or liabilities resulting from or arising out of or based upon any bodily injury or property damage which may be sustained by the undersigned or the camp participant while participating in such programs. ____________________________________________________________ Signature of parent or guardian ________________________________________ Date FIELD TRIP PERMISSION: I give my permission for my child to participate in field trips during the regular camp day, supervised by staff of Alexandria Archaeology. ________________________________________ Signature of parent or guardian ________________________________________ Date PHOTOGRAPH RELEASE: I authorize Alexandria Archaeology and the City of Alexandria to use and reproduce photographs, film and videotape taken of my child and to circulate same for advertising and publicity purposes of all kinds. ____________________________________________________________ Signature of parent or guardian ________________________________________ Date

PICK UP AUTHORIZATION

PICK UP AUTHORIZATION: I authorize the following person(s) to pick up my child from Alexandria Archaeology Summer Camp: 1. Name:     Address:     Daytime telephone: 2. Name:     Address:     Daytime telephone: Or: I authorize my child to leave on his/her own Yes: No: ____________________________________________________________ Signature of parent or guardian ________________________________________ Date If there are any changes in these authorizations, I will give written advance notice. NOTE: List below any special considerations or persons who are NEVER to be authorized to pick up your child. In the best interest of this program, its participants and Alexandria's historic resources, Alexandria Archaeology reserves the right to expel students in the case of extreme disciplinary problems. No refund will be made under these circumstances. I verify that the above information is correct to the best of my knowledge. ____________________________________________________________ Signature of parent or guardian ________________________________________ Date I wish to attend the Alexandria Archaeology Summer Camp. I understand that I will be working with irreplaceable archaeological and historic resources, and promise to abide by all rules and regulations and by the instructions provided by the staff of Alexandria Archaeology. ____________________________________________________________ Signature of camper ________________________________________ Date Return this form, with a non-refundable deposit check for $100/session made payable to the City of Alexandria, to: Alexandria Archaeology Summer Camp 105 N. Union St., #327 Alexandria, Virginia 22314 Telephone: (703) 838-4399 FAX: (703) 838-6491 e-Mail: ruth.reeder@alexandriava.gov " The balance of payment will be due by June 1. Visit us on the World Wide Web at http://oha.alexandriava.gov/archaeology/