STEM Into Summer Camper Registration Form 2019
*Once you've completed your registration here, you'll receive a confirmation email confirming your child's spot. In the event that more registrations are submitted than available spots, we will place your camper on our wait list.
Payment in full to Pfeiffer University Division of Education with "STEM Camp" in the subject line is due within two weeks of registration. Please mail to the address at the bottom of this form. We look forward to welcoming you to campus this summer!

Student's Full Name
Your answer
Parent/Guardian Name(s)
Your answer
Is the parent or grandparent a member of the faculty or staff at Pfeiffer University? If so, please list name and relationship (and deduct an additional $20/week from day camps).
Your answer
Grade Level Fall 2019
Your answer
Parent/Guardian OTHER Phone Number
Home, Work, etc.
Your answer
Street Address
Your answer
City, State, and Zip Code
Your answer
Preferred Physician Name and Phone Number
Your answer
Date of Birth
Your answer
Parent/Guardian CELL Phone Number
Your answer
Emergency Contact Name and Phone Number
Your answer
Parent/Guardian Email Address
Your answer
Alternative Transportation Arrangements
Please list any/all other persons authorized to pick up your child from camp.
Your answer
Please list any allergies to foods, medications, stings, etc.
Your answer
Preferred Hospital Name and Location
Your answer
Please list any activity restrictions or precautions.
Your answer
Please list any medications that your child is currently taking.
Your answer
Do you give Pfeiffer University, director Laura Lowder, and the Division of Education permission to publish photographs of your child on promotional materials and the camp website?
Is there any information about your child that you would like to share with the director?
Feel free to share any information that would help us to make your child's camp experience wonderful!
Your answer
Do you give the STEM Into Summer Camp director, Dr. Laura Lowder, permission to publish examples of your child's work to the camp website?
Cell Phone # to receive text messages (if any)
Your answer
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