iSTEM2 Summer Camp Registration
Take Your Place Summer Camp hosted at Bethany Union and Daley College
Email address *
Name of Child *
Your answer
Child's Birthdate *
Your answer
Current Address of Child *
please use child's current residential address
Your answer
Grade of Child *
School Name
Your answer
Parent's Name *
Your answer
Relationship to the child *
Primary Parent 1 Phone Number *
Your answer
Primary Parent 1 Email Address *
Your answer
Primary Parent 1 Address *
Primary Parent 2 Name
Your answer
Primary Parent 2 Relationship to Child
Primary Parent 2 Phone Number
Your answer
Primary Parent 2 Email Address
Your answer
Primary Parent 2 Address
Student Lives with *
Notice to Seperated Parents
Ordinarily, in the case of a student whose parents are divorced and legally separated, the parent who has physical custody pursuant to court decree or separation agreement, and person (s) designated by him or her, will be the only person(s) permitted to check out or pick up the student from camp. However, in the event the student is injured or becomes ill, or for other good and sufficient reason, if the parent who has physical custody cannot be located or cannot timely respond to the call, the school will contact the other parent or emergency contact and release the student to him or her.
Emergency Contact 1 Name *
Your answer
Emergency Contact 1 Relationship to Child *
Your answer
Emergency Contact 1 Home Phone Number *
Your answer
Emergency Contact 1 Mobile Phone Number *
Your answer
Emergency Contact 1 Work Phone Number *
Your answer
Emergency Contact 1 Address *
Your answer
Emergency Contact 2 Name
Your answer
Emergency Contact 2 Realtionship for Child
Your answer
Emergency Contact 2 Home Phone Number
Your answer
Emergency Contact 2 Mobile Phone Number
Your answer
Emergency Contact 2 Work Phone Number
Your answer
Emergency Contact 2 Address
Your answer
My child can only be pick up by *
Your answer
My child can not be picked up by *
Your answer
Does your child have any health conditions?
Does your child have any allergies?
Your answer
Does your child take any medications daily? If so, what?
Your answer
Does your child require medication to be given at camp?
If yes, a medical release form will need to be signed and returned to camp by the first day of camp (July 10, 2017).
A copy of your responses will be emailed to the address you provided.
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