Registration Form
Brainpack Summer Camp
Campers 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 2: Before Care
Week 3: Before Care
Week 4: Before Care
Week 5: Before Care
Week 6: Before Care
Week 1: Aftercare
Week 2: Aftercare
Week 3: Aftercare
Week 4: Aftercare
Week 5: Aftercare
Week 6: Aftercare
Select the weeks for summer camp
prev
next
( X )
Registration Fee
$
50.00
Week 1: June 10th- Jurassic World
$
300.00
Week 2: June 17th- Space Expedition
$
300.00
Week 3: June 24th- Builders and Engineers
$
300.00
Week 4: July 8th- Sports Mania
$
300.00
Week 5: July 22nd- Mad Scientist
$
300.00
Week 6: July 29th- Circus Fun
$
300.00
Before Care
Click the drop down arrow to select the number of weeks that you will need for before care 8am-9am. For example, if I need before care for weeks 1, 2, and 3, I will select 3 for the quantity.
$
100.00
Quantity
1
2
3
4
5
6
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
Submit
Should be Empty: