Space Journey 2007 Registration This form should be filled out by a parent or a legal guardian. ALL FIELDS ARE REQUIRED. If you do not complete the registration form correctly, you will not be accepted.
Parent or Legal Guardian Information
Name
Contact Phone:
E-mail:
Address:
City:
State:
Zip Code:
KSEA member?	Yes No
Student Information
Name
E-mail:
Gender:	Female Male
Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 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 1991 1992 1993 1994 1995 1996 1997 1998 1999
School and Grade:	Grade 5 6 7 8 9
Essay:	Tell us why you want to attend the Space Journey 2007 Camp (100-200 words)
Payment Information
Payment:	$110 student registration fee should be paid onsite.
Please read the following agreement:
1) RELEASE OF LIABILITY SECTION 35330 OF THE CALIFORNIA EDUCATION CODE STATES IN PART: "All persons making the field trip shall be deemed to have waived all claims against the center for injury, accident, illness of death occurring during or by reason of the field trip or excursion." I agree directly to my child to cooperate with directions and instructions of the camp personnel in charge of the activity 2) AUTHORIZATION FOR MEDICAL CARE Should it be necessary for my child to have medical care while participating in the camp, I hereby give the camp personnel medical care for the child, and I give my permission to the physician selected by the camp personnel to render medical care deemed necessary and appropriate by the physician. I understand the camp has no insurance covering such medical or hospital costs incurred for such treatment shall be my sole responsibility. 3) REGISTRATION Space Journey 2007 is limited to 100 students. Students are selected on first come first serve basis. $110 registration fee is paid at the door.