Summer Camp Detailed Registration Form

Summer Camp Registration

Camp Inspire is a dynamic, faith-based summer program hosted by Aspire to Inspire Tutoring & Learning Center, designed to ignite creativity, build confidence, and develop leadership in youth. Campers engage in hands-on STEM projects, art, music, financial literacy, reading and math enrichment, life skills training, and outdoor games—all in a Christ-centered environment. With small group instruction, daily devotionals, themed activities, and weekly field trips, Camp Inspire helps students grow academically, socially, and spiritually while having fun all summer long.
Student's Name*

First NameLast Name
Gender

MaleFemale
Student date of birth

MonthDayYear
Last 4 digits of student’s social*
For identification purposes only
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What school does your student currently attend?*
Please provide your student’s school ID #*
Grade
Does your student have an IEP?

YesNoI rather not answer
What is your student's T-shirt size?
Would you like to be considered for the 8-week camp scholarship?
How often will your student attend camp?
Parent/Guardian Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who does the student live with?
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 your student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is your student prescribed an inhaler or epipen? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Aspire to Inspire Tutoring & Learning Center during the camp. In exchange for the acceptance of said child’s candidacy by Aspire to Inspire Tutoring & Learning Center, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Aspire to Inspire Tutoring & Learning Center . 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 Aspire to Inspire Tutoring & Learning Center; including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all outdoor activities, including basketball, flag football, etc. Some of these injuries include, but are not limited to, scrapes, fractures, or paralysis.
Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Aspire to Inspire Tutoring & Learning Center, and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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

MonthDayYear
Date
Signature

My Products*

Camp Registration

Summer Camp Registration

$199.00 Quantity
Item subtotal:$0.00

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

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

Athlete Information
Last 4 digits of student’s social
Should be Empty:

Summer Camp Registration

Athlete Information