CSSC Course Registration Form

Registration Form

Fill out the form carefully for registration You will receive a copy of the registration form CSSC will contact you the week before the program/event with more information Your payments are processed securely through Square Are you registering Siblings? Receive a 5% discount on each registration enter code: SIBLING5 Visit www.childrensciencesociety.org for more information If you have any issues contact childrenssciencesociety@gmail.com
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Parent Name*

First NameLast Name
Parent Contact E-mail*
example@example.com
Parent Mobile Number*
Emergency Contact 1*

First NameLast Name
Emergency Contact 1 Mobile Number*
Emergency Contact 1 Alternate Number
Emergency Contact 2*

First NameLast Name
Emergency Contact 2 Mobile Number*
Please enter a valid phone number.
Emergency Contact 2 Alternative Number
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child suffer from any Medical Conditions?*
Where did you here about this program?

CSSC FacebookFriend or social media shareCSSC NewsletterExplore Science ClubPoster
Name of Signatory*

First NameLast Name
Is the Signatory authorized to sign on behalf of this child?*

YesNo

CSSC Programs and Products (select at least one)*

Kidz Science CAMP 1Mon Jul 31 to Fri Aug 4, 9am-3pm, age 5-12. Join us for a week of science fun! Hands on learning with excursions to nearby parks (eg Penzer, Buckley). $275/child, teacher to child ratio 1:12 Pickup and Drop off Alice Brown Elementary. 3 weeks notice for full refund, 2 weeks 50% refund 0/12 spots available

$275.00CAD Quantity

Kidz Science CAMP 2Mon Jul 31 to Fri Aug 4, 9am-3pm, age 5-12. Join us for a week of science fun! Hands on learning with excursions to nearby parks (eg Penzer, Buckley). $275/child, teacher to child ratio 1:12 Pickup and Drop off Alice Brown Elementary. 3 weeks notice for full refund, 2 weeks 50% refund 10/12 spots available

$275.00CAD Quantity

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Total

$0.00CAD

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