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

Format: (000) 000-0000.

Email Address

Part III - Education

School Name

Location

Part IV - Additional Children (To enroll in program)

Current Grade

Child Name

First NameLast Name

Child Age

Shirt Size (check box)

Allergies:

Emergency Contact:

Will you be willing to recommend us?

Signature

My Products

CFM Summer Camp - Drop in Rate

Register youth 5-13 for our summer camp today!! $65 Drop in Rate (sibling discount available)

$65.00 Quantity
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CFM Summer Camp - Registration Fee

Register youth 5-13 for our summer camp today!! One time $75 registration fee per child

$75.00 Quantity
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Early/After Care

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

$30.00 Quantity

Youth Summer Camp - Week 5

Register youth 5-13 for our summer camp today!! $250 a week per child (sibling discount available)

$250.00 Quantity
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Youth Summer Camp - Week 6

Register youth 5-13 for our summer camp today!! $250 a week per child (sibling discount available)

$250.00 Quantity
Item subtotal:

Youth Summer Camp - Week 7

Register youth 5-13 for our summer camp today!! $250 a week per child (sibling discount available)

$250.00 Quantity
Item subtotal:

Youth Summer Camp - Week 8

Register youth 5-13 for our summer camp today!! $250 a week per child (sibling discount available)

$250.00 Quantity
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Total

Payment Methods

Debit or Credit Card