Information

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, is not affiliated
2015 AIM Summer Camp Program
This program, while located at the University of Miami, is not affiliated, sponsored or endorsed by the University of Miami
July 13h through July 24th, 2015
9:00 AM - 3:00 PM
(There will be a charge of $20.00 per half hour for any pick-ups after 3:00 PM)
REGISTRATION FORM
Please PRINT
Parent/Guardian:
Relationship:
Address:
Phone:
Email:
Participant:
Age:
Emergency Contact:
Relationship:
Phone:
T-Shirt Size
Email:
The summer program will be held at the University of Miami School of Architecture with off-site field trips and tours
conducted on Wednesdays. Please complete this registration form as soon as possible; space is limited to 75
children.
The AIA Miami Chapter is not responsible for transportation. Parents and/or guardians are responsible to transport
AIM Camp participants to and from the University of Miami School of Architecture, all fieldtrips and tour locations.
Lunch is responsibility of the AIM Camp participant.
Cost: $225.00 for the two-week program – Attached please find the Credit Card Authorization Form
Checks payable to: AIA Miami/AIM Summer Camp Program, 100 N.E. 1st Avenue – Suite 100, Miami, FL 33132
We will inform you of the Summer Camp’s Program as soon as we have detailed description of the classes that will
be offered to the children, including the evening of the concluding Awards Ceremony and Event date, tour times and
locations. (All information will be sent via email).
Please sign below giving permission for the AIM camp participant to attend. We appreciate your support of our 2015
AIM Summer Camp.
Signature of Parent or Guardian
AIA Miami Chapter
100 NE 1 Avenue – Suite 100 – Miami, FL 33132
Phone: 305.448.7488
marilyn@aiamiami.org
@
MIAMI CENTER FOR ARCHITECTURE & DESIGN, INC.
st
100 NE 1 Avenue, Suite 100
Miami, FL 33132
One Time Credit Card Payment Authorization Form
Sign and complete this form to authorize AIA Miami to make a one-time debit to your credit
card listed below.
By signing this form you give us permission to debit your account for the amount indicated
on or after the indicated date. This is permission for a single transaction only, and does not
provide authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
I ____________________________ authorize AIA Miami to charge my credit card
(full name)
account indicated below for _____________ on or after ___________________. This payment is for
(amount)
(date)
_____________________________________.
(description of goods/services)
Billing Address ____________________________
Phone# ________________________
City, State, Zip ____________________________
Email ________________________
Account Type:
Visa
MasterCard
AMEX
Cardholder Name _________________________________________________
Account Number
_____________________________________________
Expiration Date
____________
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX) ______
SIGNATURE
DATE
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined
above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for
one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card
company; so long as the transaction corresponds to the terms indicated in this form.