Summer Intensive 2022 Name* First Last Age Birthdate* MM slash DD slash YYYY Today’s Date* MM slash DD slash YYYY Parent/ Guardian Name* Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zipcode Day Phone:*Evening Phone:Email*Used to send you a receipt and important updates Emergency ContactFill out this section if emergency contact is different from above.Name* First Last Phone*Relationship to child* Authorized Pick Up List*Please describe any allergies, learning or physical disabilities your child may have. Leave section blank if the latter doesn’t apply.ENROLLMENTPlease check the Week Session(s) your child will be attending:* Entire Session: August 15th -18th (Monday-Thursday) 9:00am-4:00pm Registration FeeHiddenWaiver I have read and agree to the Waiver and Release. Registration Total $0.00
