BASIS Tucson Organizational & Study Skills Camp
Child’s name: ____________________________________________________ 15/16 Grade: ___________________
Birth Date: ______________________ Gender: ______________________ Main Phone: ______________________
Home Address: ____________________________________________________________________________________
Parent Email: ____________________________________________________________________________________________
Please select the session your child will be attending each day:
□ Session 1
□ Session 2
□ Session 3
SMART for Charters ID #: ______________________________
*$150 registration fee must be payed through your SMART for Charters
account once you have been billed.
Tax Credit Designation:
□ Full Amount
□ $___________
□ No, thank you
1. Parent Name: __________________________________________________ Relation: ___________________________
Work Phone: ____________________ Cell Phone: ____________________ Home Phone: ____________________
2. Parent Name: __________________________________________________ Relation: ___________________________
Work Phone: ____________________ Cell Phone: ____________________ Home Phone: ____________________
EMERGENCY CONTACT: (In case of illness, accident, or emergency if parents can not be reached)
1. Name: ____________________________________ Relation: _________________ Phone: _________________
2. Name: ____________________________________ Relation: _________________ Phone: _________________
Any allergies or physical restrictions?
□ Yes □ No
If yes, please specify: _________________________________________________________________________________
Child’s Doctor: ___________________________________ Phone Number: _______________________________________
By signing below I confirm that all of the above information is correct. In case of emergency, every effort will be made to
contact the parents, the emergency contacts and doctors listed. Failing to contact any of these, I give my permission to the
school to call a physician or hospital and secure proper emergency treatment while efforts to locate parents continue.
By signing below I agree to have my SMART for Charters account billed for this transaction and agree to pay the amount
IN FULL by participants first session.
By signing below I allow BASIS Schools, Inc. and BASIS.ed their successors, and their assignees the right to record the image
and/or voice and use the artwork and/or written work of my child on videotape, film, in photographs, digital media, and in
any other form of electronic or print medium and to edit such recording at their discretion. I further grant the right to use my
child’s image and/or voice with or without their name on the internet, in brochures, and in any other medium and hereby
consent to such use. I hereby release BASIS Schools, Inc. BASIS.ed, their successors, and their assignees from all claims,
damages, demands, costs, expenses, and liabilities whatsover in connection with the above.
Arizona Tax Credit: The tax credit designation above cannot be modified one this Extracurricular Payment Form is submitted.
According to the Arizona Law (A.R.S.) § 43-1089.01, the total amount of credit for the taxable (calendar) year for contributions
made to a public school in the State supporting extracurricular activities or character education programs is limited. Taxpayers
who file a tax return as single or head of household can contribute up to $200. For married couples filing a joint tax return can
contribute up to $400. If married taxpayers file separate returns, each spouse can claim up to $200 on each return. Contributors
should review the Arizona Tex Credit Instructions or the Tax Credit Commonly Asked Questions for further information.
Parent Signature: ___________________________________________ Date: ______________________________________