2024 - 2025 - BellGrad STEAM & Sports Camp Registration Form

2024-2025 Summer Camp at Hacienda - BELLGRAD STEAM Academy

Please call us at 408-568-3674 for any clarification or email us back at hacienda@bellgrad.com
Child Name - 1*

First NameLast Name
Child Name - 1 - Birth Date*

MonthDayYear
Date
Child Name - 2

First NameLast Name
Child Name - 2 - Birth Date

MonthDayYear
Date
Home Phone Number*
Format: (000) 000-0000.
Mobile Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide any medical or dietary restrictions or any medical administration required for allergies, if none, then type N/A*

Family Information
Parent/Guardian's Name - 1*

First NameLast Name
Contact Phone Number*
Format: (000) 000-0000.
E-mail Address*
example@example.com
Parent / Guardian Name-1 Relationship to Student (Mother / Father / Guardian)*
Parent/Guardian's Name-2

First NameLast Name
Contact Phone Number - Parent / Guardian Name-2
Format: (000) 000-0000.
E-mail Address of Parent / Guardian Name - 2
example@example.com
Parent / Guardian Name-2 Relationship to Student (Mother / Father / Guardian)

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Format: (000) 000-0000.
Relationship to Student*

Acknowledgment of Enrollment

I acknowledge and confirm the enrollment information provided above regarding my child(ren)’s participation in child care services during Back-to-School Night.

Electronic Signature Agreement

By acknowledging and signing below, I am delivering an electronic signature that will carry the same effect as an original, manual paper signature. This electronic signature shall be equally binding and enforceable.

Certification of Physical Condition

I hereby certify that my child(ren) is/are in good physical condition and does/do not suffer from any condition or disability that may prevent or limit participation in the activities conducted by Bellgrad STEAM Academy.

Liability Waiver

I acknowledge that Bellgrad STEAM Academy shall not be held responsible or liable for any personal injury or damages arising from such injury during the course of participation.

Emergency Medical Authorization

In the event that Bellgrad STEAM Academy is unable to reach a parent, guardian, or listed emergency contact, I grant permission for my child(ren) to be transported to the nearest hospital or medical facility for emergency treatment.
I further authorize the staff and employees of Bellgrad STEAM Academy to approve and provide necessary medical care as deemed appropriate under the circumstances.

Cancellation Policy

Refunds will be issued only for cancellations made at least one week in advance.
No refunds will be provided for last-minute cancellations.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

2024-2025 Summer Camp at Hacienda - BELLGRAD STEAM Academy

Family Information

Emergency Contact Information