2019 SUMMER S.T.E.A.M CAMP REGISTRATION FORM June 10-14 or June 17-21 2019
Fulton Science Academy S.T.E.A.M. Camp provides fun hands-on activities in the areas of Science, Technology, Engineering, Arts and Mathematics to develop new skills, expand creative thinking, and foster team building and new friendships.
STUDENT FIRST NAME *
Your answer
STUDENT LAST NAME *
Your answer
Which Session you would like your child to attend *
BIRTH DATE *
MM
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DD
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YYYY
PARENT / GUARDIAN NAME *
Your answer
HOME ADDRESS *
Your answer
E-MAIL ADDRESS *
Your answer
PHONE *
Your answer
GRADE (check the grade your child will be in for the 2019-2020 school year) *
FERPA (Family Educational Rights and Privacy Act) Media Participation. This release applies only to positive, non-controversial stories. *
1st Emergency Contact & Authorized Person to Pick-up Student (Name, Cell Number, Relation to child) *
Your answer
2nd Emergency Contact & Authorized Persons to Pick-up Student (Name, Cell Number, Relation to child) *
Your answer
EMERGENCY MEDICAL AUTHORIZATION - Should student suffer an illness or injury while in the care of Fulton Science Academy Private School or under the supervision of its staff and is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care as may be necessary. This may include arranging transportation to an emergency room, pediatric clinic, and/or hospital. I (We) shall assume all responsibility for payment for services, included, but not limited to medical treatment and transportation of the student to a medical facility. The medical facility most often used by Fulton Science Academy Private School is as follows:North Fulton Hospital 3000 HOSPITAL BLVD., ROSWELL, GA 30076 Phone Number: 770-751-2500 *
Drug Allergies *
Your answer
Insurance Provider *
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Medical or Other Concerns (check all that apply):
My child may require the following accommodation(s) to most effectively meet his/her needs at camp:
Your answer
My child is currently taking the following medication(s) prescribed for long-term continuous use:
Your answer
Note: If student will need to take prescription medication during the camp day, please request form from Front Office.
A confirmation e-mail will be sent upon receipt of this registration form and STEAM Camp payment of $375. Please send your payment to Fulton Science Academy Private School at 3035 Fanfare Way, Alpharetta, GA 30009 to complete your registration.
If you have any questions, please contact Mr. Nevruz Turan at nturan@fultonscienceacademy.org
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