iiCamp Enroll Form

Promotional or Coupon Code

Type of Student*

New Student
Returning Student

How did you find out about us?*

Parent Information

Parent Name*

FirstLast

Home Phone*

Work Phone*

Mobile Phone 1 (for update & emergency contact)*

Mobile Phone 2 (for update & emergency contact)

Email (for class updates & announcement)*

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Student Information

Student Name*

FirstLast

Gender*

Male
Female

Date of Birth*

Current or Incoming School

Current or Entering Grade/Age*

Pick-Up Classroom # or Location

For students who need to be picked-up by i-Immersion staff or another organization based on the program detail.

Child Release Option

Indicate Authorization for Pick-Up by Selecting All Choices that Apply*

Name of Authorized Adult 1*

FirstLast

Relationship*

Primary Phone*

Name of Authorized Adult 2

FirstLast

Relationship

Primary Phone

Medical Information

Insurance Company

Policy Number

Physician

FirstLast

Phone

Dentist

FirstLast

Any allergies, medical conditions, diet, or special needs for your child.

Medical and examination reports or doctor's letter describing your child's medical conditions may be required prior to participating in the i-Immersion program.

Any allergies, medical conditions, diet, or special needs for your child.

Medical and examination reports or doctor's letter describing your child's medical conditions may be required prior to participating in the i-Immersion program.

Upload Doctor's Notes

Camp Selection

Week and Themes*

Camp T-Shirt +$15*

Payment

CHECK Payment- Payable to i-Immersion Institute at 3607 Hacienda Street, San Mateo, CA 94403 CREDIT CARD PAYMENT- There is a 5% administrative fee per credit card transaction.

Card Type

Visa
Mastercard

Card Number

Please enter a value between 16 and 16.

Expiration Date

3 Digits on Back

Please enter a value between 3 and 3.

Cardholder's Name

FirstLast

Billing Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Email for credit card receipt

Field Trip Permission

By checking the box, I give permission for my child to particpate in all field trips and special event programs planned as part of the i-Immersion Summer Camp in which this child is a participant. I hereby absolve i-Immersion, its employees and officers, from all liability, which may arise as the result of participation in the above program. I acknowledge that on the days field trips will be held, there will be no supervision provided at the i-Immersion Camp site(s) during the time period of the off-site trip.*

I agree.

Camp Participating Terms

Camp Participating Terms*

I have read and agree to the terms and conditions.

http://www.i-immersion.com/terms-conditions/

Please check each of the items below to indicate that you have read and understand the statements.*

BEHAVIOR POLICY- my child is expected to follow all rules established by his/her camp counselor, and any failure to comply will result in dismissal from the program. I also undertsand that no refunds will be given under such circumstances.
REFUND POLICY- There are no refunds once classes begin.
SIGN-OUT POLICY- my designated pick-up person or I will sign out when pcking up my child at all times.
LATE PICK-UP FEE- if I do not pick up my child before camp closes I will be charged $1.00 per minute payable to i-Immersion. No credit card is accepted.
TRANSFER- a $15.00 service fee is required to transfer from one session to another.
RETURNED CHECKS- a $25.00 fee will be charged for returned checks.

Camp Enrollment Form

Parent Information

Student Information

Child Release Option

Medical Information

Camp Selection

Payment

Field Trip Permission

Camp Participating Terms