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					COLUMBUS ACADEMY 2011 SUMMER EXPERIENCE                                                                                          LOWER SCHOOL REGISTRATION FORM
Student Information
First Name                       Last Name                                                           Birthdate           /       /                    Gender     F      M
Grade in Fall 2011               School Name                                                         District (if applicable)
Home Address                                City                                                     State          Zip                     Phone
Parent/Guardian Information
First Name                       Last Name                                                           Relationship
Home                        Cell                                        Work                              E-mail*
First Name                       Last Name                                                           Relationship
Home                        Cell                                        Work                              E-mail*
*Registration confirmations and other important information will be sent to this e-mail address.
Emergency Contact Information
First Name                           Last Name                                             Phone 1                                   Phone 2
Medical Information                                                                                                 T-Shirt Size (no additional cost--circle one)
Allergies/Chronic Medical Conditions
                                                                                                                    Youth XS S M L                      Adult S M L XL
Current Medications
 Session I June 6-9 (no camp June 10)
             Program                                   Grades    Full (9a-4p)    Part (9a-1:30p) Half (9a-11:30a) Page #
 Academics Computer Skills & Fun                         2-4      ! $200.00      ! $130.00        ! $100.00         10            Swimming Lessons                     Page 18
        Arts Art Through the Ages                        1-4      ! $200.00      ! $130.00        ! $100.00         11          ! AM (8-9) $40            ! PM (4-5) $40
             Geology Rocks!                             1-4       ! $200.00                                         13
             Graphic Design and Arts                    4-9       ! $200.00                                         13            Extended Care                          Page 2
             Medieval Castles                           K-4       ! $250.00                                         15          ! Before (7-8:30) $40     ! After (4-6) $50
             Where the Wild Things "Art"                K-4       ! $200.00      ! $130.00        ! $100.00         16
   Athletics Field Hockey Clinic (1:30-4)               2-8                      ! $165.00        ! $135.00         34
             Soccer Clinic (9-11:30)                    K-8                      ! $165.00        ! $135.00         34               Total Amount $
 Session II June 13-17
             Program                                   Grades    Full (9a-4p)    Part (9a-1:30p) Half (9a-11:30a) Page #
 Academics Keyboarding                                   2-8                     ! $155.00        ! $125.00         10            Swimming Lessons                     Page 18
        Arts Broadway Experience                         4-9      !   $300.00                                       11          ! AM (8-9) $50            ! PM (4-5) $50
             Creative Clay Creatures                     K-4      !   $250.00                                       12
             Creative Sewing I                          1-3       !   $275.00                                       12            Extended Care                          Page 2
             LEGO Amusement Park Madness                K-6       !   $275.00                                       14          ! Before (7-8:30) $50     ! After (4-6) $62.50
             Magic 102                                  K-4       !   $275.00                                       15
             Oceanography and Marine Biology            4-8       !   $250.00                                       15
   Athletics Boys' Basketball Clinic (1:30-4)           4-8                      ! $165.00        ! $135.00         34
             Football Clinic (9-11:30)                  1-6                      ! $165.00        ! $135.00         34
             Yoga for Kids                              K-4       ! $250.00      ! $155.00        ! $125.00         18               Total Amount $
Session III June 20-24
             Program                                   Grades    Full (9a-4p)    Part (9a-1:30p) Half (9a-11:30a) Page #
 Academics American Sign Language 101                    1-4      ! $250.00      ! $155.00        ! $125.00         10            Swimming Lessons                     Page 18
             Writing Around the World                    2-4      ! $250.00      ! $155.00        ! $125.00         11          ! AM (8-9) $50            ! PM (4-5) $50
        Arts Chess Kings                                K-6       ! $250.00      ! $155.00        ! $125.00         12
             Fairy Tale Flavors                         K-2       ! $275.00                                         13            Extended Care                          Page 2
             LEGO All Around the World                  1-6       ! $275.00                                         14          ! Before (7-8:30) $50     ! After (4-6) $62.50
             Let's Get Scrapbooking!                    1-4       ! $250.00                                         14
             Little Rocket Science                      K-4       ! $250.00                                         15
             Reality TV: The Lion King                  3-8       ! $300.00                                         16
   Athletics Girls' Basketball Clinic (1:30-4)          2-8                      ! $165.00        ! $135.00         34
             Martial Arts and Personal Safety           K-4       ! $250.00                                         17
             Tennis Clinic (9-11:30)                    K-4                      ! $165.00        ! $135.00         35               Total Amount $
Session IV June 27-July 1
             Program                                   Grades    Full (9a-4p)    Part (9a-1:30p) Half (9a-11:30a) Page #
 Academics Japanese Tour                                 K-4      ! $250.00      ! $155.00        ! $125.00         10            Swimming Lessons                     Page 18
             Muscle Math and Ready Writing               2-4      ! $250.00      ! $155.00        ! $125.00         10          ! AM (8-9) $50            ! PM (4-5) $50
        Arts Clay and Textiles                          K-4       ! $250.00                                         12
             Green Grows My Garden                      K-4       ! $250.00                                         13            Extended Care                          Page 2
             Project on the Runway                      4-9       ! $275.00                                         16          ! Before (7-8:30) $50     ! After (4-6) $62.50
             Rock Band                                  1-4       ! $250.00                                         16
             Safari Around the World                    K-4       ! $300.00                                         16
             Techie Camps: Robotics Camp                3-5       ! $325.00                                         16
   Athletics Columbus Crew                              K-6                      ! $165.00        ! $135.00         35
             Monster Sports                             1-6       ! $300.00                                         18               Total Amount $
 Session V July 5-8 (no camp July 4)
             Program                                   Grades    Full (9a-4p)    Part (9a-1:30p) Half (9a-11:30a) Page #
 Academics Thinking Outside the Box                      2-4      ! $200.00      ! $130.00        ! $100.00         11            Swimming Lessons                     Page 18
        Arts Adventures in Wonderland                    K-4      ! $200.00      ! $130.00        ! $100.00         11          ! AM (8-9) $40            ! PM (4-5) $40
             Art Storytellers                           1-4       ! $200.00      ! $130.00        ! $100.00         11
             Blooms & Butterflies                       K-3       ! $200.00      ! $130.00        ! $100.00         11            Extended Care                          Page 2
             Chemical Magic                             3-8       ! $250.00                                         12          ! Before (7-8:30) $40     ! After (4-6) $50
             Lemonade Stand                             K-3       ! $250.00                                         14
   Athletics Little Vikes Wrestling Clinic (9-11:30)    3-7                      ! $165.00        ! $135.00         35
             Sportsmania                                 K-4      ! $200.00      ! $130.00        ! $100.00         18               Total Amount $
                                                                                     19
           Session:        I 6/6-9      II 6/13-17      III 6/20-24         IV 6/27-7/1       V 7/5-8        VI 7/11-15         VII 7/18-22    VIII 7/25-29        IX 8/1-5        X 8/8-12
 Session VI July 11-15
              Program                                           Grades       Full (9a-4p)     Part (9a-1:30p)       Half (9a-11:30a) Page #
  Academics Thinking Outside the Box                              K-2         ! $250.00        ! $155.00             ! $125.00         11             Swimming Lessons                      Page 18
         Arts Chess Kings                                         K-6         ! $250.00        ! $155.00             ! $125.00         12           ! AM (8-9) $50             ! PM (4-5) $50
              History Detectives                                 K-4          ! $250.00        ! $155.00             ! $125.00         13
              Mixed Media                                        K-4          ! $250.00        ! $155.00             ! $125.00         15             Extended Care                           Page 2
              Oceanography and Marine Biology                    4-8          ! $250.00                                                15           ! Before (7-8:30) $50      ! After (4-6) $62.50
              Power of Bling                                     3-8          ! $250.00                                                16
              Young Superstar Academy                            K-2          ! $250.00                                                17
    Athletics Gym Skills Gymnastics & Fitness                    K-4          ! $275.00         ! $170.00            ! $140.00         17
              Sportsmania                                        K-4          ! $250.00         ! $155.00            ! $125.00         18
              Summer Horse Camp at Liberty Farm                  K-6          ! $310.00                                                18             Total Amount $
Session VII July 18-22
              Program                                           Grades       Full (9a-4p)      Part (9a-1:30p)      Half (9a-11:30a) Page #
  Academics Study Skills and Organization                         2-4         ! $250.00        ! $155.00             ! $125.00         11             Swimming Lessons                      Page 18
         Arts Bug Safari                                          K-4         ! $300.00                                                12           ! AM (8-9) $50             ! PM (4-5) $50
              Camp Invention                                      1-5         ! $275.00                                                12
              My American Girl Doll, Manners, Tea                 1-4         ! $275.00                                                15             Extended Care                           Page 2
              Papier-Mâché Mania                                  K-4         ! $250.00                                                15           ! Before (7-8:30) $50      ! After (4-6) $62.50
              Reality TV: Little Shop of Horrors                  3-8         ! $300.00                                                16
    Athletics Fencing                                             K-9         ! $275.00                                                17
              Gym Skills Cheerleading & Fitness                   K-4         ! $275.00         ! $170.00            ! $140.00         17
              Skateboarding                                      K-4          ! $275.00                                                18             Total Amount $
Session VIII July 25-29
              Program                                           Grades       Full (9a-4p)      Part (9a-1:30p)      Half (9a-11:30a) Page #
  Academics Map My World                                          2-4         ! $250.00        ! $155.00             ! $125.00         10             Swimming Lessons                      Page 18
              Simply Math and Reading                             K-2         ! $250.00        ! $155.00             ! $125.00         10           ! AM (8-9) $50             ! PM (4-5) $50
         Arts BalletMet Steps of the Stage                       K-3          ! $275.00                                                11
              Creative Sewing I                                  1-3          ! $275.00                                                12             Extended Care                           Page 2
              Hovercraft and Such                                3-8          ! $275.00                                                13           ! Before (7-8:30) $50      ! After (4-6) $62.50
              LEGO Transportation                                K-6          ! $275.00                                                14
              Life Lessons with Harry Potter                     K-4          ! $250.00         ! $155.00            ! $125.00         14
              Modern Manners & Tea Time, Too!                    1-4          ! $275.00                                                15
              Underwater Creatures                               K-4          ! $300.00                                                16
    Athletics Fencing                                            K-9          ! $275.00                                                17
              Games Galore!                                      1-6          ! $300.00                                                17
              Gym Skills Gymnastics & Fitness                    K-4          ! $275.00         ! $170.00            ! $140.00         17
              Sailing                                            1-4          ! $310.00                                                18             Total Amount $
 Session IX August 1-5
              Program                                           Grades       Full (9a-4p)      Part (9a-1:30p)      Half (9a-11:30a) Page #
  Academics Celebrate with Dr. Seuss                              K-4         ! $250.00        ! $155.00             ! $125.00         10             Swimming Lessons                      Page 18
              Simply Math and Writing                             2-4         ! $250.00        ! $155.00             ! $125.00         10           ! AM (8-9) $50             ! PM (4-5) $50
         Arts Glass Slipper Party Planning                       3-8          ! $275.00                                                13
              Jungle Bookmaking & Mixed Media                    K-4          ! $250.00                                                13             Extended Care                           Page 2
              LEGO...Sets, Sets, and More Sets                   1-6          ! $275.00                                                14           ! Before (7-8:30) $50      ! After (4-6) $62.50
              Magic 202                                          K-4          ! $275.00                                                15
              Project on the Runway                              4-9          ! $275.00                                                16
    Athletics Dance-Intensive Fitness                            3-8          ! $250.00         ! $155.00            ! $125.00         17
              Horseback Riding at Bookmark Farms                 K-4          ! $310.00                                                17
              Yoga for Kids                                      K-4          ! $250.00         ! $155.00            ! $125.00         18             Total Amount $
 Session X August 8-12
              Program                                           Grades       Full (9a-4p)      Part (9a-1:30p)      Half (9a-11:30a) Page #
  Academics Safari Readers                                        K-4         ! $300.00        ! $180.00             ! $150.00         10             Swimming Lessons                      Page 18
         Arts Chess Kings                                         K-6         ! $250.00        ! $155.00             ! $125.00         12           ! AM (8-9) $50             ! PM (4-5) $50
              Creative Sewing II                                 4-9          ! $275.00                                                12
              Digital Crafts and Scrapbooking                    3-8          ! $250.00                                                13             Extended Care                           Page 2
              Kidz Tempo                                          K-4         ! $275.00                                                14           ! Before (7-8:30) $50      ! After (4-6) $62.50
              Peter Pan's Adventures                              K-4         ! $250.00         ! $155.00            ! $125.00         15
    Athletics Martial Arts and Personal Safety                    K-4         ! $250.00                                                17
              Yoga for Girls                                      4-9         ! $250.00         ! $155.00            ! $125.00         18             Total Amount $

 PAREnT/GUARDIAn AUTHORIzATIOn AnD RELEASE                                  REgiSTRATion DEADLinES AnD fEE ASSESSMEnT                                  Sessions I - X
 •	 I	authorize	my	child	to	participate	in	the	CA Summer Program. I         Registration is not complete until payment is received. All fees are       Total Amount $
 release and forever discharge The Columbus Academy and its trustees,       due by 3:00 pm on May 20, 2011, for sessions I through V and June
 employees, agents, their heirs, successors and assigns, either jointly     17, 2011, for sessions VI through X. Cancellations or changes made
 or severally, from any and all claims, damages, obligations, causes        prior to the appropriate deadline will incur no penalty and will be
 of action or suits, resulting from bodily injury to my child or damage     refunded in full. Cancellations made after the deadline date will be       Total Late Fees $
 to or loss of my child’s property arising from participation in this       refunded at 25% of the program fee. If registrations are received af-
 program and any travel related thereto.                                    ter the deadline, a fee of 10% of the total will be assessed. Changes
                                                                            to schedule made after the deadline will be charged a nonrefund-           Grand Total $
 •	 I	permit	CA Summer Program to use, in whole or in part, photo-          able fee of $25 per child registered.
 graphs of my child in school communications.
                                                                                                                                                          Please send completed registration forms to:
 •	 I	give	permission	for	my	child	to	participate	in	supervised	swimming	   PAyMEnT infoRMATion
 activities as part of his/her CA Summer Program schedule.                                                                                                         Columbus Academy
                                                                            Acceptable forms of payment include:
 •	 In	case	of	emergency,	if	parents,	emergency	contact	person,	or                                                                                              Attn: Summer Experience
                                                                            •	 Check: payable to Columbus Academy Summer Experience                             4300 Cherry Bottom Road
 child’s physician cannot be reached by phone, I authorize CA Sum-
 mer Program to arrange for emergency medical treatment inclusive           •	 Online payment: intranet.columbusacademy.org                                        Gahanna, OH 43230
 of surgical intervention for my child, and I agree to assume liability                Choose: Parents > Tuition and Incidental Charges
 for any medical expenses incurred.                                                    Choose: click here for Credit/Debit Card payments* or                  summer office: 614.509.2267
                                                                                                click here for Checking or Savings payments                    summer fax: 614.509.2519
 Signature _________________________________________                          *There is a 2.65% convenience fee for credit/debit payments                  summer_experience@columbusacademy.org
  for business office use only:   check# ______________________________ or CC         date received ____________________         amount ____________________      received by ____________________
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