Camp Kaleidoscope

Registration/Permission Form

There are limited spaces available,which will be filled on a first come, first served basis. If more than one child in a family is registering, please fill out a separate form for each.

Camp Kaleidoscope is a FREE exciting, fun filled, learning experience sponsored by Appalachian State University’s Reich College of Education.

When: M-TH 8:00 a.m.-5:00 p.m. July 10-July 27, (Campers may sign up for 1 week, 2 weeks, or all 3 weeks if space allows)

Where: Reich College of Education Building

Cost: FREE

*The Camp Kaleidoscope program does not provide transportation or lunch. Campers should pack their own lunch. Snacks ARE provided.

Campers will be grouped with undergraduate “future teachers” from the RCOE teacher preparation program. Our program is staffed byexperienced teachers/program coordinators who, along with our tutor/mentors, will maintain constant supervision of your child/children.

If you are interested in having your rising 1st grade-rising 5th grade child/children in our Camp Kaleidoscope program, please fill out this form and return it as an e-mail attachment to -

Lou Moore:

Name of child ______

Age ______T-Shirt Size ______

Grade child is entering in Fall 2017 ______

Week/weeks desired:

July 10-13 ______

July 17-20 ______

July 24-27 ______

Name of parent(s)______

Daytime Parent phone number______

Daytime E-mail address ______

Emergency contact telephone number (in case parents can’t be reached NOTE: WE MUST HAVE AN EMERGENCY NUMBER.

______

Existing physical conditions that might warrant care/caution by supervising leaders ______

Other than parents, these people have permission to pick up my child/children from Camp Kaleidoscope ______

Consent statement –

I give permission for ASU Reich College of Education students to supervise my child while at Camp Kaleidoscope.

I am aware that my child may be workingwith Internet-based media material, under the supervision of program administrators.

I give permission for my child to participate in “on campus” field trips during Camp Kaleidoscope. Any “off campus” field trips will require written permission from me on a case by case basis.

I am also aware that there may be still and video photography of Camp Kaleidoscope program activities. I have been informed that no names of children will be used in any of that published material. Given the nature of the photography and the precautions being taken, I give my permission for my child/children to be photographed.

Parent signature ______Date ______

Your e-mail response will serve as confirmation of your typed signature.

**NOTE: You will be notified as soon as a space for your child/children is confirmed.