2024 Motivated Minds Registration

Student Information
How many students are you enrolling?
Student's Name*

First NameLast NameGrade (Fall 2024)
Student Name*

First NameLast NameGrade (Fall 2023)
Student Name*

First NameLast NameGrade (Fall 2023)
Student Name*

First NameLast NameGrade (Fall 2023)
Student Name*

First NameLast NameGrade (Fall 2023)
Any other relevant information that you would like to share:
Allergies

Bee StingPeanutsTree NutsDairyGlutenOther
Parent/Guardian Information
Parent/Guardian 1 *

First NameLast Name
Parent/Guardian 2

First NameLast Name
Phone Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number

We do not use your information for anything other than the services you select. By inputting your card information here, you are agreeing to be charged for the following selected services. Payment will be subject to a standard service tax.

Payment*

Student 1Please choose how many weeks this student will be attending camp, and then select the weeks they will be joining us.

$299.00 Number of WeeksSizeCamp Session 1Camp Session 2Camp Session 3Camp Session 4Camp Session 5

Student 2Please choose how many weeks this student will be attending camp, and then select the weeks they will be joining us.

$299.00 Number of WeeksSizeCamp Session 1Camp Session 2Camp Session 3Camp Session 4Camp Session 5

Student 3Please choose how many weeks this student will be attending camp, and then select the weeks they will be joining us.

$275.00 Number of WeeksSizeCamp Session 1Camp Session 2Camp Session 3Camp Session 4Camp Session 5

Student 4Please choose how many weeks this student will be attending camp, and then select the weeks they will be joining us.

$275.00 Number of WeeksSizeCamp Session 1Camp Session 2Camp Session 3Camp Session 4Camp Session 5

Student 5Please choose how many weeks this student will be attending camp, and then select the weeks they will be joining us.

$275.00 Number of WeeksSizeCamp Session 1Camp Session 2Camp Session 3Camp Session 4Camp Session 5

Donate a Day of CampWould you like to donate a day of camp to another child who is eager to learn and explore with us this summer? As a thank you for your donation, your family will receive a special Motivated Minds gift! (The default is listed as 4 days but you may change it to as many as you are comfortable with.)

$68.75 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to TutorPrep and its affiliates including Directors, teachers, and support staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by TutorPrep during the selected camp. In exchange for the acceptance of said child’s candidacy by TutorPrep, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless TutorPrep and all its respective directors, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

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Date
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Student Information