CAMP AKILI 2019 Camp Akili Dates are: July 29 – August 2, 2019 Registration Begins March 15, 2019 ; CAMP AKILI 2019 REGISTRATION Registration ProcessPlease complete this form to register a participant for Camp Akili. Once this application is completed please be prepared to submit registration fee. Any applications received without a payment will not be processed. Full registration fee is $450 or you can choose to make 3 installment payments in the amount of $150 for 3 months. We have limited partial scholarships. You will receive a confirmation once your application and payment have been received.Participant Name* First Last Gender Identity*Age*Date of Birth T-shirt SizeSmMedLargeXLXXLGrade LevelParticipant's Cell Phone NumberParticipant's Email Address Participant social media handles:Instagram, Facebook, and/or TwitterParent/Guardian Name #1* First Last Primary Home PhoneParent/Guardian #1 Cell Phone*Parent/Guardian #1 Work PhonePrimary Guardian #1 Email* Enter Email Confirm Email Parent/Guardian Name #2 First Last Parent/Guardian #2 Cell PhoneParent/Guardian #2 Work PhoneParent/Guaridan #2 Email* Enter Email Confirm Email Primary Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does your child live with Single Parent Both Parents Other Please list any youth programs your child is involved with.Emergency Contact Name (other than parents or guardians previously listed)* First Last Emergency Contact PhoneRelationshipFamily Physician First Last Physician PhoneHospital/Medical GroupChild's Medical NumberMedical Release* I consent In case of emergency I give consent to the staff of Flourish Agenda to seek medical care for my child.In case of emergency, and parent or doctor cannot be reached, what action do you wish to be taken?Is your child on medication? Yes No If YES, please list medicationsDoes your child have present or reoccurring health issues, special dietary needs or allergies? Yes No If YES, please list allergies, heath needs, or special dietIf your child has any special needs (behavioral, emotional, relationships) of which we should be aware, please list?PAYMENT INFORMATIONPayment to be Submitted Full payment in the amount of $450 3 installment payments in the amount of $150 I would like to apply for a partial scholarship Note: we have very limited partial scholarships. Please check the appropriate box Participant's family receives public assistance(documentation required) Participant lives with a single parent who is unemployed(documentation required) Participant lives with two parents/one parent unemployed Participant lives with a single parent Congratulations!CONGRATULATIONS! YOUR CHILD QUALIFIES FOR A PARTIAL SCHOLARSHIP TO CAMP AKILI. YOUR REDUCED FEE IS $200. ONCE YOU SUBMIT YOUR APPLICATION YOU WILL BE DIRECTED TO THE PAYMENT PAGE. PLEASE SEND EMAIL TO INFO@FLOURISHAGENDA.COM TO INQUIRE ABOUT HOW TO SUBMIT UNEMPLOYMENT VERIFICATION.UNFORTUNATELY, YOUR CHILD DOES NOT QUALIFY FOR A PARTIAL SCHOLARSHIP TO CAMP AKILI. HOWEVER, WE HAVE INSTALLMENT PAYMENTS AVAILABLE. ONCE YOU SUBMIT YOUR APPLICATION YOU WILL BE ABLE TO SELECT THE OPTION FOR INSTALLMENT PAYMENTS.If someone will submit payment on your behalf, please let us know the email address of the person who will submit payment, so that we may assign it to the appropriate participant.ACKNOWLEDGEMENT: I, parent/guardian of the above named youth, give permission for my youth to participate in Camp Akili and/or Flourish Agenda activities. I understand that Camp Akili addresses serious subject matters and social issues, sometimes using graphic content, experiential activities and emotionally intensive conversations. I give permission for media release with the understanding that any photos, articles, student work, video footage, etc from my youth may be used for promotional purposes. I understand that if my youth refuses to participate respectfully, it could result in their removal from the Camp Akili/Flourish Agenda program. I understand that Flourish Agenda staff, counselor, fellows and volunteers will take the utmost care of my child, and in the unforeseen event of lost or damaged property, or unavoidable injury or death to my child, I will not hold Camp Akili/ Flourish Agenda or its staff/board members/volunteers/fellows/counselors liable. I understand the goals of Camp Akili and gladly support my youth, and the Camp Akili/Flourish Agenda staff, volunteers, counselors, facilitators, in achieving these goals.* I Agree Refund/Cancellation PolicyFlourish Agenda can provide a refund for individual registration fees less a $50 administrative cost for up to 45-days prior to start of camp date. For organizations sending groups of 5 or more a $150 per person administrative fee will be charged for cancellations. Cancellation request within 45-days of the camp cannot be honored.