Registration Form

You will need to bring a copy of the child's current Immunization form along with their birth certificate. To ensure we are meeting your child's needs please provide a copy of their latest report card.
Student Information
Name*

First NameLast Name
M.I.
Birthday *

MonthDayYear
Date
Gender*
Grade*
Current School*
Camp Type*

Junior Summer Camp (Current or Rising 5K to 4th Grade)Middle School Zone (Current or Rising 5th - 8th Grade)Extended Day (5K to 8th Grade)
Current Residence Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Parent/Guardian Information
Parent/Guardian #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Emergency Contact 1
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship To The Student*
Sign Out*
Emergency Contact 2
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship To The Student*
Sign Out*
Physician and Medical Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Preferred Hospital*
Insurance Information
Primary Insurance Carrier *
Primary Insurance ID #*
Primary Insurance Group #*
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Photo/Video Release Form

Throughout the year the LOL STEAM CENTER and other various organizations may visit and take pictures, video, and/or audio recordings of your child. These recordings may be used in your child’s classroom, for group projects, published materials, written articles, etc. In order to allow your child to fully participate in these activities we require your signed consent. We understand that parents may have specific beliefs that may conflict with this request. Signature Below
I agree to allow my child to be audio recorded, videotaped, or photographed. I authorize the release of audio recordings, videotapes, or photographs for public viewing on local channels, for public showing, or for publication at the discretion of LOL STEAM CENTER*
Signature*

Clear
Please Upload Immunization Records

Cancelof
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty:

Insurance Information