2022 Spring Break Registration Form (April 11th to 15th) Spring Break Camp: April 11-15 Step 1 of 4 25% Which school break camp are you registering for?*Spring Break 4-6th grade (April 11-15)How did you hear about MEarth school break camps? Scholarship EligibilityThis year, MEarth is able to offer a limited number of scholarships for Spring and Summer school break camp. In order to be eligible for scholarship, you, your family, or your child(ren) must meet one of the following criteria: Eligible and enrolled in Medi-Cal health care, Eligible for free or reduced lunch in California schools, Annual income is equal to or below the poverty line as indicated by,U.S. Federal Government. If you meet any one of these requirements, please submit the relevant documentation below to be considered for a scholarship for Summer Break Camp. A MEarth Staff will be in touch regarding the status of your application. Are you eligible for a MEarth scholarship as defined above?* Yes No Proof of Scholarship Eligibility* Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 5. Please upload one of the following: A picture of scan of your child(ren's) Medi-Cal card, a copy of documentation indicating eligibility for free or reduced lunch, a copy of your 2018-2019 or 2019-2020 tax returns indicating an income level below the U.S. Federal Poverty level. I would like to register a student(s) for scholarship:A discount of 10% is automatically applied to the cost of registering multiple children in the same household. One Attendee Two Attendees Three Attendees I would like to register:A discount of 10% is automatically applied to the cost of registering multiple children in the same household. One Attendee Two Attendees Three Attendees Please list the name(s) of school break attendees below.Note that upon completion of this form, MEarth will require additional paperwork for each attendee to confirm participation in the program. Registrant InformationThe following fields ask for information about the registrant, parent, or guardian who is registering the child(ren) for MEarth school break camp. Once registration is completed, additional paperwork will be required for each child registered. Registrant First Name* First Registrant Last Name* Last Registrant Email* Registrant Phone*Registrant Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I understand and acknowledge that activities at MEarth Camp, such as hiking and working with tools, pose risks to my child, including risks of cuts, strains, sprains, sunburn, insect bites and serious injury or death. As a parent or guardian of the above named minor, do hereby, for my child, myself, my heirs, executors and administrators, release and forever discharge MEarth and all officers, directors, employees, agents and volunteers of the organization, acting officially or otherwise, from any and all claims, demands, actions or causes of action which in any way arise from the minor’s participation in the MEarth Fall Break Camp.eSignature for Participant Liability Waiver* Do you understand that all participants in this MEarth program will require full compliance with Covid-19 related safety measures, protocols, and communications, and that lack of compliance may result in the termination of their participation without refund of registration fees?* Yes No PaymentTotal $0.00
