Registration Form
Brainpack Summer Camp
Camper #1 Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Allergy
*
Camper #2 Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Allergy
Parent Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Parent #2 Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you hear about Brainpack Summer Camp?
*
Select the weeks needed for extended Care
Week 1: Before Care
Week 3: Before Care
Week 5: Before Care
Week 1: Aftercare
Week 3: Aftercare
Week 5: Aftercare
Select the weeks for summer camp
prev
next
( X )
Registration Fee
If you are registering more that 1 camper, select the quantity that correlates to the campers. For example, if I have 2 campers that I am registering, I will select 2 for the quantity.
$
50.00
Quantity
1
2
3
Week 1: June 2nd- Let's Move
If you are registering more that 1 camper, select the quantity that correlates to the campers. For example, if I have 2 campers that I am registering, I will select 2 for the quantity.
$
300.00
Quantity
1
2
3
Week 3: June 16th- Pirate Adventure
If you are registering more that 1 camper, select the quantity that correlates to the campers. For example, if I have 2 campers that I am registering, I will select 2 for the quantity.
$
300.00
Quantity
1
2
3
Week 5: June 30th- LEGO and Build
If you are registering more that 1 camper, select the quantity that correlates to the campers. For example, if I have 2 campers that I am registering, I will select 2 for the quantity.
$
300.00
Quantity
1
2
3
Before Care
Click the drop down arrow to select the number of weeks that you will need for before care 3pm-4pm. For example, if I need after care for weeks 1, 2, and 3, I will select 3 for the quantity.
$
100.00
Quantity
1
2
3
Aftercare
Click the drop down arrow to select the number of weeks that you will need for after care 3pm-4pm. For example, if I need after care for weeks 1, 2, and 3, I will select 3 for the quantity.
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Submit
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