Summer Camp Registration Template

Summer Camp Registration

For High School+Film)
Camp registration ends June 12 , 2025
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade COMPLETED in May 2025*

8th Grade9th Grade10th Grade11th Grade
Sibling's Name ATTENDING Camp (optional)

First NameLast Name
Grade Completed in May 2022 (optional)

8th Grade9th Grade10th Grade11th Grade
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
E-mail*
Confirm E-mail*
example@example.com
What STATE & COUNTY does your child attend school in?*
Emergency Information Other than the name listed above
Emergency Contact's Name*

First NameLast Name
Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Did you "Refer a Friend"? Please tell us the registered camper you invited who hasn't been to our Summer Reading Camp before!
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Powerhouse Academy during the selected camp that may include Six Flag's over Georgia, Stone Mountain, The King Center, The High Museum of Art and/or the Georgia Aquarium. Powerhouse Academy is not responsible for increased grades in school. However, we do guarantee providing each student with developmentally appropriate tasks, strategic lessons, and researched based content to improve their film and content creation performances.
Answer*

AgreeI do not agree
Media Disclosure PowerHouse Summer Academy may periodically photograph students participating and working during camp. These photographs may be used in a variety of ways; Public relations and marketing purposes: images printed on brochures, posters, and newsletters, or on PowerHouse Summer Academy's Website, Facebook Page, and/or other art, education, or news related publications. Please indicate whether you will allow publication of photographs taken of your child/children and their literacy work during classes. Names will not be included in photographs or posted on social media. We appreciate your support and would love the chance to share pictures of all of the fun being had at our Summer Reading Camp. You can also follow us on Facebook to capture all of the pictures yourself!
AgreeI do not agree
Registration Fee Non-Refundable $5672
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.
Signature

Powered by Jotform SignClear
Checkout

Registration includes registration fee AND camp date selection. Students are not enrolled until full payment is received. Discount for siblings will be applied at checkout.

My Products

Camp Registration

$5,672.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Should be Empty:

Summer Camp Registration

Checkout

Payment Methods