Electronics Maker
Monday - Thursday
July 15 - 18, 2019
9:00 AM - 4:00 PM
IRSC Main Campus, Fort Pierce, FL
Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Child's Age *
Where does the child attend school? *
Your answer
List all Parents/Guardians authorized to pick-up and drop-off your child at the LASER-TEC bootcamp
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian Email Address (if different from e-mail provided above)
Your answer
Parent/Guardian Name (2)
Your answer
Parent/Guardian Phone Number (2)
Your answer
Parent/Guardian Email Address (2)
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
List any additional parents/guardians authorized to pick-up & drop-off your child here. Please include telephone numbers.
Your answer
How did you learn about this LASER-TEC bootcamp? *
Required
Has your child previously attended any bootcamps offered by LASER-TEC? *
If you answered "Yes" to the above question, please let us know which camps your child has attended.
Your answer
Important Information
After the registration form is submitted, a parent/guardian will receive an email with three forms that are required to be filled out, signed, and submitted to LASER-TEC before a student is admitted to any LASER-TEC boot camp. The completed forms should be sent to wkeiser@irsc.edu or mailed to:

William Keiser
Indian River State College,
3209 Virginia Ave, Fort Pierce, FL 34981
Brown Center for Innovation and Entrepreneurship

For questions, please contact Will Keiser at 772.462.7074 or wkeiser@irsc.edu

A copy of your responses will be emailed to the address you provided.
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