Cultivate Fertile Minds Application

Part I - Personal Information

Applicant Name*

First NameLast Name

Child Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Shirt Size (check box)

Allergies:

How did you hear about us?*

Part II - Parent/Guardian

Parent Name*

First NameLast Name

Phone Number*

Email Address*

Part III - Education

School Name*

Location*

Current Grade*

Part IV - Additional Children (To enroll in program)

Child Name *

First NameLast Name

Child Age*

Shirt Size (check box)

Allergies:

Emergency Contact:

Will you be willing to recommend us?

YesNo

My Products

WINTER DAY CAMP - WEEK 1Register for our youth camp today!! Dec. 16th - Dec. 20th

$90 Quantity

WINTER DAY CAMP - WEEK 1 (Family of 2 Package)Register for our youth camp today!! Dec. 16th - Dec. 20th

$170 Quantity
Item subtotal:$0.00

WINTER DAY CAMP - WEEK 2Register for our youth camp today!! Dec. 23rd, 24th*, 26th, 27th

$90 Quantity
Item subtotal:$0.00

WINTER DAY CAMP - WEEK 2 (Family of 2 Package)Register for our youth camp today!! Dec. 23rd, 24th*, 26th, 27th

$170 Quantity
Item subtotal:$0.00

WINTER DAY CAMP - WEEK 3Register for our youth camp today!! Dec. 30th, 31st*, Jan. 2nd, Jan. 3rd

$90 Quantity
Item subtotal:$0.00

WINTER DAY CAMP - WEEK 3 (Family of 2 Package)Register for our youth camp today!! Dec. 30th, 31st*, Jan. 2nd, Jan. 3rd

$170 Quantity
Item subtotal:$0.00

Early/After CareWeekly flat rate option per child if Early/After Care is needed

$25 Quantity

Total

$0.00

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