Summer Camp Enrollment Form

Summer Literacy Camp Registration

A Silhouette Private Tutoring and Enrichment Services LLC
Thank you for your intrest in Gold Minds Child Enrichment Services Literacy Camp! We look forwrad to meeting and serving you!
CHILD INFORMATION:
Child Name *

First Name Last Name
Birth Date *

Month Day Year
Grade *
Name of School *
Session Preference
Class Preference
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Emergency Contact
Name
Emergency Contact
Phone Number
MEDICAL INFORMATION
Physician Name

First Name Last Name
Phone Number

Area Code Phone Number
Medical Concerns
How will you pay for Literacy Camp?

One-Time Payment Payment plan Reading Scholarship (if Approved) Gardiner Scholarship

Camp Deposit

Literacy Program Deposit $ 52.50

Deposit is non-refundable.There is 5% Processing fee with all card transactions. This deposit will hold your spot for literacy service.

Total $ 0.00

Please send over child's 2020-2021 or latest English Language Arts FSA testing results to contact@goldmindsenrichment.com
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Summer Literacy Camp Registration