Registration Form

Registration Form

Brainpack Summer Camp
Camper #1 Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Allergy
Camper #2 Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Allergy
Parent Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent #2 Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Brainpack Summer Camp?

Select the weeks for summer camp

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

Week 1: June 1st- Sports Mania

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

Week 2: June 8th- Ooey Gooey Science

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

Week 3: June 15th- Junior Paleontologist

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

Week 4: June 22nd- The Shark Lab

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

Week 5: July 8th-10th- Pokemon

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.

$180.00 Quantity

Week 6: July 13th- LEGOs 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

Enter coupon

Subtotal

Tax

Total

Should be Empty: