Summer Camp Registration

SUMMER CAMP REGISTRATION
Child's Name *

First Name Last Name
Camp Opportunities:

July 16-20: MEDIEVAL WEAPONS $ 140.00

Extended Care (before/after camp) - Medieval Weapons $ 30.00

July 16-20: WHIZZ! POP! BANG! MAD SCIENCE - CAMP IS FULL - PLEASE REGISTER IF YOU'D LIKE TO BE PLACED ON OUR WAITLIST $ 140.00

Extended Care (before/after camp) - Whizz! Pop! Bang! Mad Science Camp $ 30.00

July 30-Aug. 3: LEGO NINJAGO INSPIRED TRAINING CAMP $ 140.00

Extended Care (before/after camp) - Lego Ninjago Training Camp $ 30.00

July 30-Aug. 3: DEEP SEA DISCOVERY $ 140.00

Extended Care (before/after camp) - Deep Sea Discovery $ 30.00

Total $ 0.00
Once you click SUBMIT below, you will be directed to pay online with Visa, Mastercard, or Paypal. If you do not wish to pay online, please contact Pure Genius to make other payment arrangements.

PLEASE NOTE: There is a maximum of 12 campers per session. A minimum of 8 campers must register or the camp will be cancelled.
My child will be in _____ grade in September 2018. *

1st 2nd 3rd 4th 5th 6th
Mom, dad, or legal guardian: *

First Name Last Name
Phone Number *

- Area Code Phone Number
Home Address: *
State *
Zip: *
E-mail *
Mom, dad, or other legal guardian:

First Name Last Name
Phone Number:

- Area Code Phone Number
Does your child have any health conditions or allergies that we should know about? If so, please explain:
Emergency Contact: *

First Name Last Name
Emergency Contact Telephone Number: *

- Area Code Phone Number
RELEASES: In case of emergency, I give permission for my child to be treated as necessary at my expense. Pure Genius provides active, hands-on workshops. All reasonable attempts will be made to ensure your child’s safety. A child whose behavior endangers others or is not conducive to the workshop environment will be removed from the workshop without refund. Parents and guardians agree not to hold Pure Genius Educational Learning Center, Incorporated, Christine Celis, or any of their employees, agents, or representatives, responsible for any accidents or injuries that occur. Photos and videos of students and activities are taken during the workshops and they may be publicly shared and used in promotional materials. If you do not wish for your child to be photographed, please notify the instructor in writing, on or before the first workshop. Pure Genius is not licensed and is not required to be licensed by Bright From the Start. Pure Genius does carry liability insurance. All workshops must meet minimum enrollment or they will be cancelled. The aforementioned releases apply to all past/present/future enrollments. By clicking "Submit," I agree to these terms and conditions.
PLEASE NOTE: Your child is not registered for camp until you pay in full. Since we limit each of our camps to only 12 students in order to provide an optimal learning enviroment for your little genius, Pure Genius cannot "hold spaces" for any campers for any reason. Registration is on a first-come, first serve basis!

Please call (423) 385-5040 if you have any questions. THANKS!
CA$H for Referrals

Did a friend refer you to Pure Genius? If so, they will get $10 cash for each referral made on/before May 25th. Cash referrals will only be paid if you list their information below at the time of registration and your child attends one of our camps. This offer is void if you register for camp and your child does not attend. Cash for referrals will be paid out on the Friday afternoon after your registered camp ends.
Person who referred you to Pure Genius:

First Name Last Name
Phone Number of the person who referred you to Pure Genius:

- Area Code Phone Number
Should be Empty:

SUMMER CAMP REGISTRATION

CA$H for Referrals