STEM Camp Registration Form (Grades 3

(Esprit de Corps Center for Learning does not discriminate based on race, color, national or ethnic origin in the administration of its hiring policies, student admissions, or other school-administered programs).
STEM Camp Registration Form (Grades 3–12)

Welcome! Please complete this form to register your student for our upcoming STEM Summer Camp. All fields marked with * are required.
Student Information

Student Full Name
Name*

First NameLast Name
Grade (Entering Fall 2025)*
Date of birth*

MonthDayYear
Date
School Name*
T-Shirt Size*
Parent/Guardian Information*

First NameLast Name
Relationship to Student:*
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Name, Relationship, Phone)*
Medical & Safety Information

Your child's safety and wellbeing is important to us. Please type in any applicable information for the areas listed below.
Allergies (food, medicine, etc.):*
Medical Conditions or Special Needs:*
Medications Taken Regularly*
Permission for Emergency Medical Treatment:*
Permissions and Agreements
Extended Hours Required?*

yesnoundecided
Drop-in Required (daily vs. weekly?*

yesnoundecided
Sibling Discount needed?*

yesno
Authorized Drop-off/Pick-up Persons (Names & Phone Numbers)*
Photo/Video Release Consent*

YesNo
Code of Conduct Agreement*

I acknowledge and agree to review the behavior guidelines with my child.
Liability Waiver Agreement:*

I agree to the terms and conditions.
STEM Interests (Optional)
What STEM topics does your child enjoy?
Previous Camp or STEM Experience
Payment & Scholarships

Please indicate how payment is being made. Payments via Zelle can be sent to hcmfundaccount@hopechapelministries.org. If paying in person, the address is 9840 Wagner Road, Jacksonville, FL 32219. If paying through Eventbrite, use link: https://EDCSTEM.eventbrite.com
Indicate how payment is being made:*

I am paying using Eventbrite -- Use Link: https://EDCSTEM.eventbrite.comI am paying in person by cash, check or money orderI am paying by Zelle to hcmfundaccount@hopechapelministries.org
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STEM Camp Registration Form (Grades 3–12)

Student Information

﻿Medical & Safety Information

Permissions and Agreements

STEM Interests (Optional)

Payment & Scholarships

Medical & Safety Information