Camp Registration

STEMulate Your Mind Camp 110 Clay St. Warner Robins Ga

Name of Student *

DOB

Date

Grade Level *

Gender *

Male Female

Military Dependent? *

Yes No

GA Caps Prgram

Name of Parent/ Legal Guardian *

Phone(c)

Phone(w)

Email *

example@example.com

Notification person 1 *

example@example.com

Notification person 2 *

example@example.com

Notification person 3 *

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country of Residence

Emergency Contact List(other than parents)/Authorized Pickup List *

I give permission for my child to be photographed. I understand the photographs are the property of PinkSTEM and may be used in any manner including but not limited to promotional (media,flyers,banners,etc.) related material to PinkSTEM.

Signature

Clear

MEDICAL INFORMATION

Please state any health information or allergies we may need to know. If your child has special needs, please let us know. We want to help our staff be prepared for the needs of your child. Food items are sometimes used during our programs. Please use additional paper if needed. (Mandatory medications be left at the front desk prior to drop off with instructions prior to each session) *

List all present medications *

Should your child be restricted from any activity? *

Yes No

If yes so,please explain:

Release and Waiver of Liability *

(initial)

In the event my child suffers an illness or accident requiring medical treatment while involved in PinkSTEM, I hereby give permission for any necessary hospitalization, medication, or surgery on recommendation of medical personnel, in which case all such expenses shall be paid by me. In the event of sickness or accident, I waive all claims against PinkSTEM, its members, officers, agents, employees, and volunteers that may arise from participants in the activities of PinkSTEM. The undersigned hereby acknowledges that they have read, understand, and agree to all documents related to PinkSTEM programs, including the Handbook/Guidelines and Discipline policy. The undersigned hereby waives all claims against PinkSTEM and its employees or volunteer workers for injury,accident or illness by reason of participation in the PinkSTEM program.

Signature

Clear

Date

Total

Scholarship Recipient

Yes No

Pink S.T.E.M. T-Shirt Size

CANCELLATION POLICY

All sales are final. No refunds, cancellations must be received with a 30 day written notice and reasonable verification given to Pink S.T.E.M.Inc via email info@pinkstem.org. A 25% cancellation fee will be deducted before a 30-day Cancellation, a 50% cancellation fee will be deducted within 30 days. The fee includes a camp Shirt. Your tuition may be transferred to a future class that occurs prior to December 2022, but only immediately upon your cancellation. No refund or transfer requests will be accepted within five (5) business days of the start of a class or if you do not attend.
*A 10% administrative fee is retained for cancellations not initiated by Pink S.T. E.M. Inc.
Payment is required by noon on Thursday before the first class in order to reserve your spot in the class.

CAMP REGISTRATION