SUMMER ECO-CAMP  REGISTRATION FORM
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Student’s Name *
Grade *
School’s Name *
Father’s Name *
Father's Phone *
Father Email
Mother’s Name *
Mother’s Phone *
Mother’s Email
Home Address *
Emergency contact name *
Emergency Phone *
How did you hear about us? *
Payment Method *
Photographed : *
The student may be photographed as part of the documentation. The Sekolah Mutiara Nusantara also may use these pictures for promotional materials. Your signature allows the use of photographs for promotion purposes.
Required
For students: *
 I am aware that when I am on a Summer Eco camp program, I am under the jurisdiction and supervision of the school – employed sponsors/chaperones and that my behavior must conform to the Code of Student Conduct and reasonable instructions from chaperones. I  will be subject to appropriate disciplinary action for violations of these rules and regulations.
Required
For parents: *
We, the undersigned parents/guardians, have been fully advised as to the nature and possible dangers and hazards during trip. Does hereby give permission for the designated representatives to act on our behalf authorizing medical and hospital treatment for the health and well being of our child during the trips. We release Sekolah Mutiara Nusantara, the school foundation and their employees from and waive all claims for injury, accident, illness, death or property damage occurring during or by reason of said field trip or excursion, and arising from any cause whatsoever including illegal acts of third parties. All financial cost that occur during the incident will be our responsibility as parents/guardians.
Required
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