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Arts & Cultures S.T.E.A.M. CAMP 2019
Session 1: June 10-13, 2019 (Monday-Thursday) 9 a.m. - 2 p.m.
Session 2: June 17-20, 2019 (Monday-Thursday) 9 a.m. - 2 p.m.

Early Bird Registration $35 (Due upon enrollment before 03/31/2019)
Registration $40
$100 per week (Due May 1st)

Registration is due upon enrollment. Your application cannot be processed until we have your registration payment. Please visit our website at www.mosaicacademy.org (pay online) to pay your registration and camp tuition online. You may also pay cash/check to our Mosaic Academy office.

Which camp session(s) will your child be participating in? *
Required
Child's Name: *
Your answer
Gender: *
Birth Date: *
MM
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DD
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YYYY
Grade for the 2019-2020 academic school year: *
Your answer
Home Address: *
Your answer
Home Phone:
Your answer
Mom's Name: *
Your answer
Mom's cell: *
Your answer
Mom's work number:
Your answer
Mom's email: *
Your answer
Dad's Name: *
Your answer
Dad's cell: *
Your answer
Dad's work number:
Your answer
Dad's email: *
Your answer
Special Needs/Allergies:
Your answer
Please list anyone who you will allow to pick up your child from camp. This list will be used in an emergency if you cannot be reached. A driver's license will be needed in order to release your child.
Your answer
Medical Release: In case of an emergency, I give my permission for Mosaic Academy to seek medical attention for my child __________________ (please type child's name). *
Your answer
Medical Release: In the event that hospital care is required, I prefer that treatment be sought at _______________ (please type name of hospital). *
Your answer
Photo/Video Release: *
T-Shirt Size: *
Application Agreement: All information contained on this application is confidential and will not be shared with anyone outside of Mosaic Academy staff. By submitting this application we are committing to participate in the summer camp at Mosaic Academy. We understand our registration fees are not refundable. We understand that tuition for summer camp must be paid by May 1st. We understand that after May 15th, only 50% of camp tuition can be refunded. We understand that summer camp tuition is non-refundable after June 1st. *
Your answer
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