Lumos Academy Summer Camp Registration

Fall 2024 Application

Thank you for you interest in Lumos Academy. We are excited to partner with you on your childs learning journey. Please fill out the form below and we will be in touch soon to schedule your family interview.
Student Information
Student Name*

First NameLast Name
Age*
Child T-Shirt Size*
Birth Date*

MonthDayYear
Current School*
Current or Recent Grade Completed*
Gender

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Relationship*
Parent Email*
example@example.com
Parent/Guardian Information 2
Name

First NameLast Name
Cell Number
Relationship
Parent Email
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Does your child have any allergies or medical conditions? If yes, please describe in detail.*
Has your child been diagnosed with any learning disabilities or other conditions we should know about? *
Has your child ever been kicked out or expelled from any learning instituition? If yes, please explain. *
What do you like most about your childs current school or previous schools he or she has attended?*
What do you think is the best way for your child to learn?*
What fears, if any, do you have about your child's school experience?*
Do you have any questions for us? *
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Lumos Academy and affiliates during the selected camp(s) and academic school year. In exchange for the acceptance of said child’s candidacy by Lumos Academy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Lumos Academy and all its respective owners, agents, employees, 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.

In case of injury to said child, I hereby waive all claims against Lumos Academy, including all owners, employees and affiliates, as wall as all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named child, 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, undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical treatment deemed medically neccessary for the named child. 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 Lumos Academy and its affiliates including employees to call 911 emergency services and/or transport my child to a medical facility for emergency treatment.

Release authorized on the dates and/or duration of the 2024- 2025 Academic year.

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.
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*

MonthDayYear
Date
Signature*

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Fall 2024 Application

Student Information