PowerHouse Academy Summer Camp Application Form
Student Information
Name
First Name
Last Name
Grade
School Last Attended
Gender
Please Select
Male
Female
N/A
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Has the student been suspended from Middle or High School?
Yes
No
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first
*
Name
First Name
Last Name
Relationship
Phone Number
Format: (000) 000-0000.
Have this child had any serious illnesses or operations?
Yes
If yes, please describe
Can this child take part in regular physical activities?
Yes
No
Do you want to indicate any related information?
Date of Registration
-
Month
-
Day
Year
Date
My Products
*
prev
next
( X )
Application fee
$30 Application Fee plus $5 tax and fees
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
ACH Bank Transfer
Submit
Should be Empty: