Student Registration Form

Student's Name

First NameLast Name

Birth Date

MonthDayYear

2024-2025 Grade Level

I am registering for:

(The AM session is for students who will be in First, Second, or Third grade in 2024-2025. The PM session is for students who will be in Fourth, Fifth, or Sixth grade.)

Phone Number

Email

example@example.com

Parent/Guardian Information

First NameLast Name

Cell Phone Number

Please enter a valid phone number.

E-mail

example@example.com

Emergency Contact

First NameLast Name

Cell Phone Number

Please enter a valid phone number.

Relationship

ex. Father, Mother, etc.

Please describe any allergies or medical conditions the student may have.

Medical Insurance Carrier

Policy #

Child's Doctor

Preferred Hospital

Please list all people other than yourself who are authorized to pick up your child:

Waiver & Release

By signing this form, I/we certify that I/we request and give permission for my/our child to participate in this camp. I/we release and save harmless the instructors and any and all of its employees from any and all liability for any and all harm arising to my son/daughter as a result of this camp, and waive any claims against them.

EMERGENCY MEDICAL TREATMENT:

I/we give permission for my/our child to be transported by ambulance and/or to be treated in the event of a medical emergency.

Payment & Cancellation Policy

I understand that my FACTS account will be charged for the full, non-refundable amount of $250 before the first day of camp.

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.

Signature