Summer Camp Detailed Registration Form

Child Name (List multiple first names if there are multiple children)

First NameLast Name

Birth Date

MonthDayYear

Grade

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Beautiful Minds Learning, LLC during the selected camp. In exchange for the acceptance of said child’s candidacy by Beautiful Minds Learning, LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Beautiful Minds Learning, LLC and all its respective officers, agents, 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 Beautiful Minds Learning, LLC including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

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

Signature

My Products

June 9-12th Botany & Ecosystems Camp

10AM-1PM. Make terrariums, solar ovens and garden smoothies, art projects and reading. $99 is price per child, please select the correct quantity below for multiple children. Please pack a small lunch.

$99.00 Quantity

June 23-26 American Symbols and Heroes Camp

10AM-1PM. Create fireworks in a glass, build your own monument, cook fire cracker dogs and make a patriotic cake! $99 is price per child, please select the correct quantity below for multiple children. Please pack a small lunch.

$99.00 Quantity

July 7-10 Fairytales and Problem Solving Camp

10AM-1PM. Magical potions, Thumbelina's house project, make stone soup and green eggs and ham! $99 is price per child, please select the correct quantity below for multiple children. Please pack a small lunch.

$99.00 Quantity

July 21-23 American Pioneers Camp

10AM-1PM. Log cabin challenge, rag dolls, johnny cakes and hand pies galor! $75 discounted price per child for this holiday week that helps you prepare your child for celebrating Pioneer Day. Please pack a small lunch.

$75.00 Quantity

August 4-7 Outer Space Camp

10AM-1PM. Rocket launch, rover challenge, meteor meatballs and Saturn Rings projects. $99 is price per child, please select the correct quantity below for multiple children. Please pack a small lunch.

$99.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Summer Art/STEM/Cooking Camp Registration

Information