Summer Camp 2023 STEAM School Co-op Registration

Summer Camp 2023 STEAM School Co-op Registration
Parent(s)*

First NameLast Name
First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Cell)

Area CodePhone Number
Phone Number (Home)

Area CodePhone Number
Email
example@example.com
Secondary Email
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Who has permission to pick up your child?
Is there anyone who DOES NOT have permission?
Please choose the week or weeks you are registering for.*

Week 1 - Tuesday June 20th and Thursday June 22ndWeek 2 - Tuesday June 27th and Thursday June 29th
Student Information
Camper 1*

First NameLast Name
Age
What would you like us to know about your child?(Special needs, any diagnosis, best teaching practices, interests, etc.)
Camper 2

First NameLast Name
Age
What would you like us to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Camper 3

First NameLast Name
Age
What would you like us to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Camper 4

First NameLast Name
Age
What would you like us to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Camper 5

First NameLast Name
Age
What would you like us to know about your child? (Special needs, any diagnosis, best teaching practices, interests, etc.)
Fee Agreement
I will be dropping off one or more children for summer camp. My camp fees will be... (see above schedule to determine your drop off fees per number of children being dropped off)
Confirmation of registration will be sent within 7 days via email and the first half of summer camp fees will be due at that time.

Payment of the camp fee secures my requested space in the 2023 summer camp. Once my registration has been confirmed, payment can be mailed by check to The STEAM School at P.O. Box 112, Markham, VA 22643 or via QuickBooks. The second half of camp fees will be invoiced on June 1st and due by the first day of camp. I understand that all of these fees are non-refundable.
I agree to this by typing my name below. *

Photo Release
Type a question*

I grant to the STEAM school, its representatives and volunteers the right to take photographs of me and my children during STEAM co-op time or STEAM events. I authorize the STEAM school to use and publish the photos in print and/or electronically.I do not grant permission for photos to be taken of my childI grant permission for photos to be taken of my child for use on our internal parent app, Bloomz, only
If OTHER: I grant permission for my child to be used in publication under the following conditions...
I agree to this photo release by typing my name:*

Medical release
For Drop off parents only: I designate the following person to serve as a parent proxy in my absence, (Either a friend, or our coordinators, Beth Herz and Tamara Fickling)
By signing this form, I hereby waive the STEAM School, its officers and members, from any liability of injury and loss or damage of personal property associated with participating in this event. I understand that my children are under the care of a parent proxy, not the STEAM School. By typing my name below, I acknowledge that I understand this waiver.
Name and date*
Medical Information
Pediatrician
Phone Number

Area CodePhone Number
Allergies or other medical conditions
Insurance Information (name, provider, group#, policy#)
Email
example@example.com
Should be Empty:

Summer Camp 2023 STEAM School Co-op Registration

Student Information

Fee Agreement

Photo Release

Medical release

Medical Information