Kids Camping Registration

Healthy Minds ESTEAM Builders Clubs

Imagine. Paint. Build. Create.
Parent/Guardian Information
Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number*

Area CodePhone Number
Child Information
Child's Name*

First NameLast Name
Age *
Gender*
Birth Date*

MonthDayYear
List allergy concerns: (If any)
List medical concerns: (If any)
Emergency Phone #:*
Emergency Contact Relationship:*
Same as aboveDifferent
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Pictures will be taken of the children during the program for our website. Forms will be available at the club if you do not want your child's picture included.
healthymindslearn.org
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Healthy Minds ESTEAM Builders Clubs