Student's Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

MM

DD

YYYY

Gender

Boy

Girl

Parent/Guardian Name #1

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Parent/Guardian Name #2

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Emergency Contact #1

First Name

Last Name

Phone

(###)

###

####

Emergency Contact #2

First Name

Last Name

Phone

(###)

###

####

Summer Options

The entire Summer (all 10 weeks) - $1710 Total *Must register by June 1st to qualify for discounted rate*

Week by Week (Choose which weeks below)- $190 per Week

Week One (June 9-13)

Week Two (June 16-20)

Week Three (June 23-27)

Week Four (June 30-July 3) No program July 4

Week Five (July 7-11)

Week Six (July 14-18)

Week Seven (July 21-25)

Week Eight (July 28-Aug 1)

Week Nine (Aug 4-8)

Week Ten (Aug 11-15)

Authorized Pickup #1

First Name

Last Name

Phone

(###)

###

####

Authorized Pickup #2

First Name

Last Name

Phone

(###)

###

####

Authorized Pickup #3

First Name

Last Name

Phone

(###)

###

####

Authorized Pickup #4

First Name

Last Name

Phone

(###)

###

####

Anticipated Pickup Time

Hour

Minute

Second

AM PM