Summer Camp Sign Up Form

Summer Camp Registration

For (add grade level + subject area)
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
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*
Alt. Phone Number
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by (insert tutoring name here) during the selected camp. (insert tutoring name here) 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 reading and/or math performance.
Type a question*

AgreeI do not agree
Price Registration Fee Early Bird Special Until May 22nd $40 2 Weeks: $280 Non-Refundable $320 after May 21st
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.
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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.
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Camp Registration
$40.00

June 21 - July 2
$280.00 Number of Students

Total

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Summer Camp Registration

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