Math and Chess Summer Camp Registration
Student Name (First Last) *
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Date of Birth (MM/DD/YY) *
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Parent/Guardian Name (First Last) *
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Relationship to Child
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Contact Number *
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Primary Email *
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Parent/Guardian/Emergency Contact Name (First Last) *
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Relationship to Child
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Contact Number *
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School Name *
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Student's Grade in Fall 2019 *
Camp Session and Time- all other sessions besides Session 2 PM are full (including wait lists) *
I give permission for my child to receive emergency medical care *
Health Concerns/Allergies/Other Special Instructions
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By signing below I agree to release any and all claims, demands, causes of action, remedies and damages against Perfect Square Learning, LLC, their agents and employees, including all claims and causes of action of negligence, personal injury, and property damage or loss. Refunds will only be given upon cancellation of a camp session. No other refunds will be given. First and Last Name Electronic Signature *
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