Summer Aspirations Program Registration Form

Student/Participant Information

Child First Name(Required)

Child Middle Initial

Child Last Name(Required)

Date of Birth(Required)

Child Gender(Required)

My child is on track to graduate in: (enter graduation year)(Required)

Child Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child Cell Phone (Enter N/A if none)(Required)

Child Email (Enter N/A if none)(Required)

Child's T-shirt Size(Required)

Please indicate the size, including youth or adult. If youth or adult isn't specified, we will default to an adult size.

I give permission for my child to be photographed while on campus. I understand the photos will be used for marketing purposes only.

Yes

No

Health Information

Enter "NONE" if the field is not applicable.

Allergies(Required)

Medications(Required)

List any current condition and any recent surgeries, hospitalizations illnesses, or injuries(Required)

Health Insurance

Health Insurance Provider(Required)

Policy Number(Required)

Emergency Contact Information

Parent/Guardian Name(Required)

First Last

Parent/Guardian Cell Phone(Required)

Parent/Guardian Email(Required)

Choose from one of the options below:(Required)

Emergency Contact Information is the same as Parent/Guardian already listed

Emergency Contact Information is DIFFERENT than Parent/Guardian already listed.

Emergency Contact Information(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Summer Program Selection

Please enter a quantity of 1 next to each program that you're registering this participant for. There is no limit to the number of programs each participant can attend.

Inside Out

Price: $25.00

Creative Writing

Price: $25.00

How Did These Bananas Get Here?

Price: $35.00

Mechanical Codes & Food Safety

Price: $25.00

Boys Basketball Skills Clinic

Price: $150.00

Computer Build & Play

Price: $0.00

Girls Youth Softball Camp

Price: $50.00

Girls HS Softball Elite Camp

Price: $50.00

Learning Laser Cutting

Price: $0.00

Fun with Forensics

Price: $0.00

Wooden Car Derby

Price: $50.00

Let's Pasta 'Bout It!

Price: $0.00

Girls Youth Soccer Clinic

Price: $150.00

HS Boys Basketball Shooting Clinic

Price: $150.00

Be a Healthcare Hero!

Price: $35.00

Science is Magic!

Price: $25.00

Boys Youth Soccer Clinic

Price: $150.00

Boys High School Soccer Camp

Price: $150.00

Elite High School Girls Soccer Camp

Price: $350.00

Total Registration Cost

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Untitled

First Choice

Second Choice

Third Choice