C
amp Internet Individual Leader Application


For Individual Teachers, Lab Coordinator, Afterschool Program Sites or Libraries

I am enrolling in Camp Internet as a:

New participant Returning Camper
And am a:
Teacher Afterschool Program Leader Librarian Technology/Lab Coordinator

I am enrolling in ONE of the following Camp Internet Online Expeditions:

Discover the California Channel Islands (suggested for grades 4 - 9)

Explore the Ancient Southwest (suggested for grades 5 - 9)

Resdicover America's Original Promise (suggested for grades 5 - 12)

Explore the Global Garden (suggested for grades K-12)

Discover the California Backcountry (suggested for grades 3 - 12)

Explore GIS Mapping (suggested for grades 4 - 12)

Services Ordered
I am ordering the following services and/or products:

Single Camp Internet Teacher year round subscription w/online professional development & Tool Kit $299

With a (select one) GPS Digital Still Camera Digital Video Camera Scanner

Live Training Workshop for one teacher for professional development ( please contact me about details)

Contact Information

Teacher/Project Leader's Name

Teacher/Project Leader's Work Email

School / Agency Name

Site Location - Street Address

City State Zip

Site Phone Site Fax

URL

Principal/Directors Name

Principal/Directors Email

Teacher/Project Leader's Home Address

City State Zip

Home Phone

Home fax

Social Security Number

I am also ordering the following (tax and handling/shipping incl):

GPS unit/s $120 each                                      Set of 25 passports & stickers $50 each
Digital Still Camera/s $120 each                    Additional Mascots $12 each
Digital Video Camera/s $120 each                Additional Mousepads $8 each
Scanner/s $120 each                                       Field Notebooks $8 each
Other

How many students will be in your class?
How many computers do they have access to?
What type of Computers do they have access to?
What is the speed of Internet at your school?

Payment Method - enrollment and materials fees are due by July 5th unless other arrangements have been made.

Total cost of services / products ordered $

I am submitting a purchase order/s for my individual enrollment ( you can provide one PO or seperate for program/materials/training)

Agency issuing PO:

Contact for PO - Name
Phone Fax
PO# PO# PO#

(I am not filling in the payment information because I am included in a purchase order from my:
school district afterschool site library I am interested in applying for a RAIN, USDA or BIA School scholarship)

I will be paying by credit card MC Visa Am Ex
In Full - or - Monthly over 12 months

Card #
Exp Date
Card Holders Name
Card Holders Address

I will be paying by check sending with signed application will follow signed application
Name
Address
City State Zip

What grade level do you teach?

What is your teaching specialization?

Agreement

This enrollment agreement includes opportunties for training for myself, online programs for my students,and optional mateirals and/or live training. By enrolling, I agree, on behalf of my school or agency, to pay the program package costs, and will be responsible for any travel or field costs or liabilites. I and my students will observe the Camp Internet Accpetable Use Policies for responsible online activities and we will participate fully to the best of our abilities.

Please print, then submit online, and then sign this application/mail a hard copy to
Camp Internet
1129 State Street A7
Santa Barbara CA 93101
(if you decide later to make changes on this form, do so by hand and send in with signature)

Signature
Date
Thanks for Enrolling!
Questions? Call 1-800-889-2823, or email explore@campinternet.net