The Maricopa County Community College District (MCCCD) is an EEO/AA institution and an equal opportunity employer of protected veterans and individuals with disabilities. All qualified applicants will receive consideration for
employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, or national origin. A lack of English language skills will not be a barrier to admission and participation in the career and technical
education programs of the District.
The Maricopa County Community College District does not discriminate on the basis of race, color, national origin, sex, disability or age in its
programs or activities. For Title IX/504 concerns, call the following number to reach the appointed coordinator: (480) 731-8499. For additional
information, as well as a listing of all coordinators within the Maricopa College system, http://www.maricopa.edu/non-discrimination.
GATEWAYCC.EDU/DISCOVER
GateWay Community College | Washington Campus
108 N. 40th Street, Phoenix, AZ 85034
WEEK 1 | CAMP GECKO’S GOT TALENT | MAY 25-29
Campers will nd their inner superstar at Camp’s Gecko’s Got Talent week!
This week will give the campers a chance to showcase their own unique
talents and prepare themselves fo
r a fabulous camp-wide performance at
the end of the week.
WEEK 2 | AMAZING ANIMALS | JUNE 1-5
Have fun learning about dierent types of animals. Throughout the week
will explore animal habitats, the types of foods they eat, and learn how
we can help take care of them. We will take a eld trip to the Phoenix Zoo
where children will have the opportunity to see real animals and learn how
zoos help animals stay healthy and safe.
WEEK 3 | ALL ABOUT ARIZONA | JUNE 8-12
Arizona is full of history and places to explore. Throughout the week,
we will learn about the geology of Arizona and the rst people to make
Arizona their home. We will take a eld trip to the Heard Museum where
we will learn about plants and animals that are native to Arizona while also
exploring Native American culture and history.
WEEK 4 | MYSTERY WEEK | JUNE 15-19
Calling all amateur sleuths! This week we’ll put YOU in the detective’s
chair so you can develop your critical thinking and problem-solving skills.
Children will participate in a live-action game of “Clue” across the whole
campus. Do you have what it takes to catch whodunit?
WEEK 5 | THE POWER OF STEAM | JUNE 22-26
Join us for a week of exploration, experiments, art projects and math games.
Throughout the week, children will enjoy activities that will teach them all about
Science, Technology, Engineering, Art and Math. To enhance their experiences,
children will take a eld trip to the Arizona Science Center.
WEEK 6 | WHEN I GROW UP | JUNE 29-JULY 3
Community helpers are all around us. This week, children will have the
opportunity to learn about and meet community helpers that work all around
us. Through their experiences, children will have the opportunity to learn about
the dierent types of work that people do. Children will engage in pretend play
and creative activities to enhance their understanding of careers. This week we
will take a eld trip to the Hall of Flame Fire Museum.
WEEK 7 | GO GREEN | JULY 6-10
Planet Earth is the most valuable resource to children. Throughout the week,
children will learn what it means to be a good steward of their community.
Children will have the opportunity to create projects with recycled materials,
learn about zero waste, help build an earthworm-composting garden and
participate in a community service project. This week we will take a eld trip
to the Rio Salado Audubon or the Botanical Gardens.
WEEK 8 | COMMUNITY SERVICE | JULY 13-17
Community, equity and equality are current conversations happening around
our country. It is important for children to learn how they t in to their
community and how they can support, serve and provide a positive impact.
Throughout the week, children will learn about dierent types of community
service. They will have the opportunity to collect information about services
they care about, learn how other children created their own community
service initiatives and nd ways to participate in those projects. During the
week, children will go on a eld trip to Feed My Starving Children where
they will learn about children around the world who are suering from food
poverty. During the experience, children will pack food for starving children
from another country.
WEEK 9 | KIDS BAKING CHALLENGE | JULY 20-24
This week will be an awesome week of baking exploration. Throughout the
week children will learn all about the kitchen and how to bake. At the beginning
of the week, children will learn about kitchen and food safety. After children
learn how to be safe, they will have the opportunity to learn about baking
techniques, cupcake decorating and food presentation. At the end of the week,
children will engage in their very own, cupcake baking challenge. Each team
will bake and decorate a group of cupcakes that will then be judged by our very
own special guest judges. During the week, we will take a eld trip to tour a local
bakery and learn some baking skills from a professional.
WEEK 10 | SUMMER OLYMPICS | JULY 27-31
Get excited for the 2020 Summer Olympics this week! Phoenix is the
perfect place to engage in an assortment of athletic and sporting activities.
Throughout the week, children will have an opportunity to explore and
assortment of physical activities indoors and out. We will take a eld trip to
the swimming pool and to a local sporting event so that children can relate
their own sports ideas to real life events.
MORE INFORMATION
Please contact Leia Wilson at (602) 286-8135 or leia.wilson@gatewaycc.edu
CAMP GECKO
AGES: 6-12
WHEN: Monday-Friday | 6:30 AM TO 6 PM
WHERE: Main Building | MA1100 N/S
PRICE: $175 per week (includes breakfast, lunch & snacks)
GateWay Community College now oers a dynamic summer camp
experience for children ages 6-12 years old. Your child will have the
opportunity to experience eight weeks of excitement through crafts, eld
trips and themed activities. Each week children will have the opportunity to
choose from a variety of activities that will help them create memories to
last a lifetime. Call (602) 286-8130 or email for cost and more information.
Breakfast, lunch, two snacks and all eld trips included in the cost.
STEP
1
STEP
2
Create MEID Account using PARENT NAME
Apply for Admission
maricopa.edu/admissions
To complete STEP 1, submit proof of
identification to the college at which you applied.
PAY TUITION AND FEES
Explore Payment Options
maricopa.edu/paying-for-college
MEID : __________ _____________________________________________
You will use it to log on to all Maricopa student tools.
Student ID Number: ______________________________________________
You will use it to register and to pay your tuition costs.
Maricopa Email: _________________________________________________
Activate your email at: google.maricopa.edu
Make a note of your password in a secure place.
My Current Balance is:
$_____________________
Pay on or Before Due
Date:__________________
Navigate to My.Maricopa.edu
Select the
Make a Payment
icon
Log-in using your MEID and current
password
Select the type of payment you would
like to make, including enrolling in
payment plans
Enroll in Payment Plan if you are behind
in payments
Monitor your Student Center for current
balance
(complete these steps online and/or in person)
GET ADMITTED
ENROLLMENT STEPS
Chandler-Gilbert | Estrella Mountain | GateWay | Glendale | Mesa | Paradise Valley | Phoenix | Rio Salado | Scottsdale | South Mountain
GateWay Children's Learning Center
108 N 40th Street
Phoenix, AZ 85034
For Academic Career, select
Non Credit Class
For Primary College of Interest, select
GateWay Community College
To complete the application, select
Generate Your Username
The Maricopa County Community College District (MCCCD) is an EEO/AA institution and an equal opportunity employer of protected veterans and individuals with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual
orientation, gender identity, or national origin.
REV. 01/2017
Parent Name: __________________________________________________ Fall 20______ Spring 20_______ Summer 20_______
DES
Child________________________________________
Child’s Birthday_______________________________
Student ID#__________________________________
Pin Number ______________For_________________
Pin Number ______________For_________________
Parent_____________________________________________
Address___________________________________ Apt______
City__________________________________ Zip___________
Phone # ____________________________________________
Email Address________________________________________
Monday Tuesday Wednesday Thursday Friday
Drop Off: Drop Off: Drop Off: Drop Off: Drop Off:
Pick Up: Pick Up: Pick Up: Pick Up: Pick Up:
ACKNOWLEDGEMENT:
By signing below I acknowledge that I have read and understand the tuition guidelines for all summer camp programs at
GateWay Community College. I understand that my child will not be permitted to attend camp if guidelines are not adhered
to:
1. It is my responsibility to keep current on CLC scheduled activities and due dates by reading all correspondence placed on my sign-in/out
sheets or in my child’s cubby/mailbox, reviewing the CLC calendar, and monitoring parent whiteboards, email messages, and Procare
messages.
2. GateWay Children’s Learning Centers will apply a $10 registration fee upon enrollment for all of our summer camp programs. The
registration fee is a one-time fee. Registration fees are non-refundable. The 2020 Camp Gecko tuition is $175 per week. The camp is open
Monday-Friday from 6:30am-6:00pm. Children can be dropped off and picked up any time during the hours of the summer camp on any
day Monday-Friday, except when the camp is on a field trip. Camp Gecko is a flat tuition rate and cannot be pro-rated.
3. Throughout the summer, Camp Gecko will take field trips. A field trip t-shirt is required for all children who will participate. A one-time,
$10 t-shirt fee is applied upon enrollment for Camp Gecko. The t-shirt will stay at camp and be laundered by camp staff after each field
trip. Each child will be allowed to keep their shirt and take it home after their last date of attendance at Camp Gecko.
4. The cost of the camps will include all of the field trips, meals/snacks and supplies. Camp tuition is non-refundable unless the camp is
canceled due to low enrollment. All summer camp tuition fees, must be paid in full no later than the Wednesday before the camp starts.
5. Once your complete application is received, your child will be registered for the chosen summer camp(s) and you will be notified via e-mail
(at the e-mail address you provide). Payment must be received by Wednesday prior to the start of each registered camp. If payment has
not been received in full, your child will not be admitted. Payment may be made on-line through your Maricopa Student Center or in
person at the GateWay Community College Cashier’s Office located in the IE building on the Washington campus. Summer camp fees are
non-refundable unless the camp is canceled due to low enrollment.
_______________________________________________
Signature
____________________
Date
Children’s Learning Center
GateWay Community College
Week 1: May 25-29 Camp Gecko's Got Talent
Week 2: June 1-5 Amazing Animals
Week 3: June 8-12 All About Arizona
Week 4: June 15-19 Mystery Week
Week 5: June 22-26 The Power of STEAM
Week 6: June 29-July 3 When I Grow Up
Week 7: July 6-10 Go Green
Week 8: July 13-17 Community Service
Week 9: July 20-24 Kids Baking Challenge
Week 10: July 27-31 Summer Olympics
Camp Gecko Registration Form 2020/2021
Private Pay
CCAMPIS
S U M M E R C A M P E N R O L L M E N T L I S T ( S E L E C T A L L T H A T A P P L Y )
COMPLETED ENROLLMENT FORMSP A Y M E N T P L A N
OTHER
COMPLETED ORIENTATION FORMS
Immunizations
EIIR Card
Student ID
CACFP Income
Eligibility
DES Best of
Care
Behavior
Contract
Travel
Assumption
Registration
Form
Health
Insurance
Photo
Release
Start Date:
Mother
Father
CDC/SGH# or name:____________________
Arizona Department of Health Services
Bureau of Child Care Licensing
Emergency, Information and Immunization Record Card
Child’s Name:
Date Enrolled:
Home Address (#, Street, City, State, Zip Code):
Home Phone:
Date of Birth:
Parent or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
Parent or Guardian Name:
Home Address (#, Street, City, State, Zip Code):
Cell Phone (optional):
Contact Telephone Number:
I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted:
(Pursuant to R9-5-304.B, at least two contact persons are required.)
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
Name:
Contact Telephone Number:
If Medical care is necessary, call:
Health Care
Provider*
Name:
Contact Telephone Number:
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
In case of injury or sudden illness,
I request that this individual be called first:
The following individual(s) may NOT remove my child from the facility:
Name(s):
Custody papers have been provided and are on file at the facility. yes no
Telephone Authorization Code (optional):
G:\Forms\Emergency Information and Immunization Record Card (6/16)
Immunization Information
(A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and
Immunization Record card.)
For information regarding current immunization requirements go to:
www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630.
One of these items must accompany the EIIR card at all times:
Copy of current official documented immunization record attached
Religious Beliefs exemption form signed by parent/guardian attached
Medical Exemption form signed by physician and parent/guardian attached
Signed Laboratory Proof of Immunity form attached
Notification of immunizations needed sent to Parent(s) or Guardian(s):
mo /day/ yr
mo /day/ yr
mo /day /yr
Updated immunizations received and attached:
mo /day/ yr
mo /day/ yr
mo /day /yr
Medical Information
Is child allergic to food or other substances?
No Yes
If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:
Is child usually susceptible to infections and if so, what precautions need to be taken?
No Yes
If yes, list precautions
:
Is child subject to convulsions and what should be our procedure if one occurs?
No Yes
If yes
, specify procedure
:
Is there any physical condition that we should be aware of and what precautions should
be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)?
No Yes
If yes, list precautions
:
Additional comments:
Other special instructions:
This Emergency Information and Immunization Record Card is accurate and complete, front and back, and was provided by:
Parent/Guardian PRINTED Name:
SIGNED Name:
DATE:
Children’s Learning Center
108 North 40
th
Street
Phoenix, Arizona 85034
(602) 286-8130
GateWay Community College Summer Camp
Behavior Contract
I, ________________________________ agree to participate in this program in a cooperative, positive
(Child’s Name)
manner. I understand that the teachers and staff will help me make appropriate choices in my
behavior. Should I choose not to cooperate or make appropriate choices I understand and accept
that I will:
Receive a warning
I will be removed from the classroom and given a moment to regain my composure
If the above does not help my behavior choices then my parent(s) will be notified. If the behavior
continues, my parents will be required to pick me up and I will not be able to return for the rest of the
day.
I have read and understand the above consequences of my behavior. My parent(s) and I have
discussed this information, and they agree to the above.
Child’s Signature: ________________________________________________________________________________
Parent’s Signature: ____________________________________________________ Date: _____________________
Summer Camp T-Shirt Order Form
Throughout the summer, children may participate in field trips off campus. Children are required to
wear a summer camp t-shirt in order to participate in the field trip. This helps our summer camp staff
identify the children that belong to our program. In addition to the t-shirt, each child will wear a
name badge and information to identify that they are a participant in our program. Please use the
form below to identify what size t-shirt your child will wear.
Youth Size:
Small Medium Large Extra Large
T-shirts will be kept at the summer camp and washed after each field trip. At the end of the child’s
enrollment, they will be able to take their t-shirt home.
CCA-1200AFORFF (4-16) Page 48 Arizona Department of Economic Security
CCA-1200A FORFF (4-16) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Child Care Administration
BEST OF CARE
This confidential form is to help your child care provider support the growth and development of your child while creating a safe,
stable and healthy environment for all children. By providing complete information about your child, you will be assisting us in
creating a positive experience for your child while in child care.
Instructions: This form is to be completed by a parent/guardian and must be on file at the child care facility on or before a child’s
first day of attendance. If additional space is needed, attach a separate sheet of paper.
CHILD’S NAME
DATE OF BIRTH
PARENT/GUARDIAN COMPLETING THIS FORM
WHAT IS YOUR PREFERRED METHOD OF COMMUNICATION?
PROVIDER/CENTER NAME
Has your child attended child care in the past? Yes No
If yes, what type of setting(s) was your child in? (Family child care, group care, etc.)
What did you like most about your child’s previous child care setting?
What did you like least?
Other comments:
What is important to you about your child’s care?
Who is important to your child?
Does your child prefer to play alone or with other children? Alone Other children
Does your child have a favorite toy or comfort object? Yes No
If yes, what?
What is your child’s current sleep schedule?
Does your child fall asleep easily? Yes No
What is his/her mood upon waking?
What does your child like?
What does your child dislike?
See reverse for EOE/ADA/LEP/GINA disclosures
Email
GateWay Children's Learning Center - Main Campus
CCA-1200AFORFF (4-16) Page 49 Arizona Department of Economic Security
CCA-1200A FORFF (4-16) Page 2
CHILD’S NAME
Special things you say or do to comfort your child are?
How do you know when your child is:
Happy?
Sad?
Mad?
Tired?
Other?
How does your child react when:
Something unexpected happens?
Something happens he/she doesn’t like?
He/She is scared?
Other?
Does your child have any health issues?
Yes
No
If yes, please explain:
Does your child have any other special needs? Yes No
If yes, please explain:
Events at home often influence a child’s behavior, for example: changes in the family, such as a new sibling, separation or divorce,
or moving to a new home. Knowing about these transitional times will allow us to provide special attention, understanding, and care
that your child needs.
Has anything happened recently in your child’s life that might have an effect on him/her? Yes No
If yes, please explain:
Is there anything else you would like to share about your child that you feel would help us create a positive environment and
relationship for your child?
Parent/Guardian declined to complete
Parent/Guardian Signature
Date
Equal Opportunity Employer/Program Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the
Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable
accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the
Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also
means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including
making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of
your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further
information about this policy, contact 602-542-4248; TTY/TDD Services: 7-1-1. Free language assistance for DES services is available upon
request. Disponible en español en línea o en la oficina local.
Definition of Household
Member: “Anyone who is
living with you and shares
income and expenses, even
if not related.”
Children in Foster care and
children who meet the
definition of Homeless,
Migrant or Runaway are
eligible for free meals. Read
How to Apply for Free and
Reduced Price School
Meals for more information.
Are you unsure what
income to include here?
Flip the page and review
the charts titled “Sources
of Income” for more
information.
The “Sources of Income
for Children” chart will
help you with the Child
Income section.
The “Sources of Income
for Adults” chart will help
you with the All Adult
Household Members
section.
X X
2020-2021 Child and Adult Care Food Program Meal Benefit Income Eligibility Application
Complete one application per household. Please use a pen (not a pencil). (Child Care Centers)
Child’s First Name MI Child’s Last Name
Age
Enrolled?
Yes No
Foster
Child
Homeless,
Migrant,
Runaway
If NO
> Go to STEP 3.
If YES > Write a case number here then go to STEP 4 (Do not complete STEP 3)
Write only one case number in this space.
A. Child Income
Sometimes children in the household earn or receive income. Please include the TOTAL income received by all
Household Members listed in STEP 1 here.
B. All Adult Household Members (including yourself)
Child income
$
How often?
List all Household Members not listed in STEP 1 (including yourself) even if they do not receive income. For each Household Member listed, if they do receive income, report total gross income (before taxes)
for each source in whole dollars (no cents) only. If they do not receive income from any source, write ‘0’. If you enter ‘0’ or leave any fields blank, you are certifying (promising) that there is no income to report.
Name of Adult Household Members (First and Last)
Earnings from Work
$
How often?
Public Assistance/
Child Support/Alimony
$
How often?
Pensions/Retirement/
All Other Income
$
How often?
$ $ $
$ $ $
$ $ $
$ $ $
Total Household Members
(Children and Adults)
Last Four Digits of Social Security Number (SSN) of
Primary Wage Earner or Other Adult Household Member
Check if no SSN
“I certify (promise) that all information on this application is true and that all income is reported. I understand that this information is given in connection with the receipt of Federal funds, and that determining officials may verify (check) the information. I am aware that if I purposely
give false information, my children may lose meal benefits, and I may be prosecuted under applicable State and Federal laws.”
Street Address (if available)
Apt #
City
State Zip Daytime Phone and Email (optional)
Printed name of adult signing the form Signature of adult Today’s date
STEP 2
Do any Household Members (including you) currently participate in one or more of the following assistance programs: SNAP, TANF, or FDPIR?
Report Income for ALL Household Members (Skip this step if you answered ‘Yes’ to STEP 2)
STEP 4
Contact information and adult signature
Check all that apply
Case Number:
Weekly Bi-Weekly 2x Month Monthly
Weekly Bi-Weekly 2x Month Monthly
Weekly Bi-Weekly 2x Month
Monthly
Weekly Bi-Weekly 2x Month
Monthly
X X X
STEP 1
List ALL Household Members who are infants, children, and students up to and including age 18 (if more spaces are required for additional names, attach another sheet of paper)
We are required to ask for information about your children’s race and ethnicity. This information is important and helps to make sure we are fully serving our community.
Responding to this section is optional and does not affect your children’s eligibility for free or reduced price meals.
Ethnicity (check one):
Race (check one or more):
Hispanic or Latino Not Hispanic or Latino
American Indian or Alaskan Native
Asian
Black or African American Native Hawaiian or Other Pacific Islander White
The Richard B. Russell National School Lunch Act requires the information on this application. You do
not have to give the information, but if you do not, we cannot approve your child for free or reduced price
meals. You must include the last four digits of the social security number of the adult household member who
signs the application. The last four digits of the social security number is not required when you apply on
behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary
Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations
(FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household
member signing the application does not have a social security number. We will use your information to
determine if your child is eligible for free or reduced price meals, and for administration and enforcement of
the lunch and breakfast programs. We MAY share your eligibility information with education, health, and
nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for
program reviews, and law enforcement officials to help them look into violations of program rules.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations
and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race, color, national origin, sex,
disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or
funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille,
large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they
applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made
available in languages other than English.
To file
a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,
(AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or
write a letter addressed to USDA and provide in the letter all of the information requested in the form. To
request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil
Rights 1400 Independence Avenue, SW
Washington, D.C. 20250-9410
fax: (202) 690-7442; or
email:
program.intake@usda.gov.
This institution is an equal opportunity provider.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice a Month x 24 Monthly x 12
How often?
Eligibility:
Total Income
House
hold Size
Categorical Eligibility
Determining Official’s Signature
Dat
e
Confirming Official’s Signature
Date
Sources of Income for Children
Sources of Child Income
Example(s)
- Earnings from work
- A child has a regular full or part-time job
where they earn a salary or wages
- Social Security
- Disability Payments
- Survivor’s Benefits
- A child is bl
ind or disabled and receives Social
Security benefits
- A Parent is disabled, retired, or deceased, and
their child receives Social Security benefits
-Income from person outside the household - A friend or extended family member
regularly gives a child spending money
-Income from any other source
- A child receives regular income from a
pri
vate pension fund, annuity, or trust
INSTRUCTIONS Sources of Income
OPTIONAL Children's Racial and Ethnic Identities
Do not fill out
For Official Use Only
Sources of Income for Adults
Earnings from Work
Public Assistance /
Alimony / Child Support
Pensions / Retirement /
All Other Income
- Salary, wages, cash
bonuses
- Net income from self-
employment (farm or
business)
If you are in the U.S. Military:
- Basic pay and cash bonuses
(do NOT include combat pay,
FSSA or privatized housing
allowances)
- Allowances for off-base
housing, food and clothing
- Unemployment benefits
- Worker’s compensation
- Supplemental Security
Income (SSI)
- Cash assistance from
State or local
government
- Alimony payments
- Child support payments
- Veteran’s benefits
- Strike benefits
-
Social Security
(including railroad
retirement and black lung
benefits)
-
Private pensions or
disability benefits
-
Regular income from
trusts or estates
-
Annuities
-
Investment income
-
Earned interest
-
Rental income
-
Regular cash payments
from outside household
Weekly Bi-Weekly 2x Month Monthly
Free Reduced Paid
MC-AORROL-TRVL (03/07/11) PAGE 1 of 2
MARICOPA COUNTY COMMUNITY COLLEGE DISTRICT
2 4 1 1 W e s t 1 4
th
S t r e e t , T e m p e , A Z 8 5 2 8 1 - 6942
TRAVEL ASSUMPTION OF RISK & RELEASE OF LIABILITY
For Students
Caution: This is a release of legal rights. Read and understand it before signing.
The Maricopa County Community College District is a public educational institution. References to College
("College") include all of the Colleges within the Maricopa County Community College District ("MCCCD"), its
officers, officials, employees, volunteers, students, agents, and assigns.
I ______________________________, freely choose to participate in the ______________________ (henceforth
referred to as the “Program”). In consideration of my participation in this Program, I agree as follows:
SPECIFIC HAZARDS OF TRAVEL: (Specific dangers endemic in this Program’s area of travel.)
INSTITUTIONAL ARRANGEMENTS: I understand that College is not an agent of, and has no responsibility
for, any third party which may provide any services including food, lodging, travel, or other goods or services
associated with the Program. I understand that College is providing these services only as a convenience to
participants and that accordingly, College accepts no responsibility, in whole or in part, for delays, loss, damage
or injury to persons or property whatsoever, caused to me or others prior to departure, while traveling or while
staying in designated lodging. I further understand that College is not responsible for matters that are beyond its
control. I acknowledge that College reserves the right to cancel the trip without penalty or to make any
modifications to the itinerary and/or academic program as deemed necessary by College.
INDEPENDENT ACTIVITY: I understand that College is not responsible for any loss or damage I may suffer
when I am traveling independently or I am otherwise separated or absent from any College activity. In addition, I
understand that any travel that I do independently on my own before or after the College sponsored Program is
entirely at my own expense and risk.
HEALTH AND SAFETY: I have been advised to consult with a medical doctor with regard to my personal
medical needs. I state that there are no health-related reasons or problems that preclude or restrict my
participation in this Program. I have obtained the required immunizations, if any.
I recognize that College is not obligated to attend to any of my medical or medication needs, and I assume all risk
and responsibility therefore. In case of a medical emergency occurring during my participation in this Program, I
authorize in advance the representative of the College to secure whatever treatment is necessary, including the
administration of an anesthetic and surgery. College may (but is not obligated to) take any actions it considers to
be warranted under the circumstances regarding my health and safety. Such actions do not create a special
relationship between the MCCCD and me. I release the MCCCD, its officers, officials, employees, volunteers,
students, agents and assigns from all liability for any bodily injury or damage I sustain as a result of any medical
care that I receive resulting from my participation in Program, as well as any medical treatment decision or
recommendation made by an employee or agent of the MCCCD. I agree to pay all expenses relating thereto and
release College from any liability for any actions.
TRAVEL CHANGES: If I become separated from the Program group, fail to meet a departure airplane, bus, or
train, or become sick or injured, I will, to a reasonable extent, and at my own expense seek out, contact, and reach
the Program group at its next available destination.
MC-AORROL-TRVL (03/07/11) PAGE 2 of 2
ASSUMPTION OF RISK AND RELEASE OF LIABILITY: Knowing the risks described above, and in
voluntary consideration of being permitted to participate in the Program, I agree to release, indemnify, and defend
College and their officials, officers, employees, agents, volunteers, sponsors, and students from and against any
claim which I, the participant, my parents or legal guardian or any other person may have for any losses, damages
or injuries arising out of or in connection with my participation in this Program.
SIGNATURE: I indicate that by my signature below that I have read the terms and conditions of participation
and agree to abide by them. I have carefully read this Release Form and acknowledge that I understand it. No
representation, statements, or inducements, oral or written, apart from the foregoing written statement, have been
made. This Release Form shall be governed by the laws of the State of Arizona which shall be the forum for any
lawsuits filed under or incident to this Release Form or to the Program. If any portion of this Release Form is
held invalid, the rest of the document shall continue in full force and effect.
Signature of Program Participant
Date
Signature of Parent or Legal Guardian (if student is a minor)
Date
Date: ____________________ Location: _____________________________________________________
Department: ______________________________Photographer*: ___________________________________
I authorize the Maricopa Community Colleges (including its colleges and related entities) to photograph or
video me and to use the photographs or videos for educational or promotional purposes in any type of media.
The photographs or videos may not be used for profit without my express permission. I understand that
I will not be paid or rewarded for providing this authorization.
1. _____________________________________________________________________________________________
Name (please print) Signature
_____________________________________________________________________________________________
Description of clothes*
(color, type: t-shirt, dress shirt, skirt, etc.)
_____________________________________________________________________________________________
Quote
2. _____________________________________________________________________________________________
Name (please print) Signature
_____________________________________________________________________________________________
Description of clothes*
(color, type: t-shirt, dress shirt, skirt, etc.)
_____________________________________________________________________________________________
Quote
PARENT / GUARDIAN PERMISSION (if under 18 years old)
1. _____________________________________________________________________________________________
Name (please print) Signature
_____________________________________________________________________________________________
Description of clothes*
(color, type: t-shirt, dress shirt, skirt, etc.)
_____________________________________________________________________________________________
Parent / Guardian
(if under 18 years old)
Witness
2. _____________________________________________________________________________________________
Name (please print) Signature
_____________________________________________________________________________________________
Description of clothes*
(color, type: t-shirt, dress shirt, skirt, etc.)
_____________________________________________________________________________________________
Parent / Guardian
(if under 18 years old)
Witness
*Optional
MC-PUPQ (04/27/16)
Chandler-Gilbert | Estrella Mountain | GateWay | Glendale | Mesa | Paradise Valley | Phoenix | Rio Salado | Scottsdale | South Mountain
The Maricopa County Community College District (MCCCD) is an EEO/AA institution and an equal opportunity employer of protected veterans, and individuals with disabilities.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
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