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Brain Buster Camp Registration Form
Date:
Monday, August 12th
PM Session:
12:00pm-3:00pm
Price:
$35 per learner *Cost includes all camp materials and a snack*
Ages:
4+
*If you have more than one child to register, please fill out an additional form.
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* Indicates required question
AM or PM Session
*
PM Session 12:00pm-3:00pm
Student Name (First & Last)
*
Your answer
Parent Name (First & Last)
*
Your answer
Parent Email Address
*
Your answer
Primary Emergency Contact Name (First and Last/Relation)
*
Your answer
Primary Emergency Contact Phone Number
*
Your answer
Secondary Emergency Contact Name (First and Last/Relation)
*
Your answer
Secondary Emergency Contact Phone Number
*
Your answer
Age and birthday of learner- Example: Age 5 (Sept. 30th, 2017)
*
Your answer
Health Concerns (allergies, medical, etc) *If none please state n/a
*
Your answer
Other Concerns/Important Information (Family, behavior, etc) *If none please state n/a
*
Your answer
Please read the following consent and mark yes or no.
I give consent to Little Learners Academy for my child to be transported and receive medical aid as may be necessary and expedient by a licensed physician/surgeon in case of an emergency when parent/guardian cannot be reached.
*
Yes
No
Please read the following consent and mark yes or no.
I give consent to Little Learners Academy to use photographs or videos of my child for any legal use including but not limited to: publicity, copyright purposes, advertising, and web content.
*
Yes
No
I would like to pay using the following method
*
Direct payment to Little Learners via invoice sent in email
Cash (Please drop off the day of the camp)
Check (Please drop off the day of the camp)
Free Camp Coupon (bring coupon the day of camp as payment)
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