Academy Registration Form

ETHOS Science Academy Registration
Spring 2018

Tuesday                       9:30 - 11:30 includes snack                                         $75.00
Wednesday                3:30 – 5:30 includes snack                                          $75.00
Sibling discount          Non-scholarship students                                            $70.00
Scholarship rate         per student                                                                  $40.00

• Please fill out one form per child, per class.
• The form(s) must be completed and returned by 1 week prior to start date to guarantee a spot for your child.
• A minimum $25 deposit is required to hold your spot.
• Balance of registration fees must be received 7 days prior to the start of camp.
• If mailing form(s), please allow sufficient time to meet the deadlines.

As a part of registration, you will have to include the payment confirmation code given to you after completing your transaction below. A receipt including your code will also be emailed to you. If you would prefer to pay through phone, mail, or at our location, contact [email protected] to proceed with registration.

Spring 2018 Registration Form

* Indicates required field

Class Day *

Class Title *

Child's Name *

First

Last

Child's Gender *

Child's Age *

Grade *

Child's Birthdate (MM/DD/YYYY) *

School Attending *

Address *

Line 1

Line 2

City

State

Zip Code

Country

To which racial or ethnic group(s) do you most identify? *

Need for scholarship? *

Yes

Parent/Guardian's Name *

First

Last

Email *

Emergency Contact Name, Relationship to Child, and Phone Number *

Transportation Arrangement (fill out all areas that apply)
My child has permission to leave class with the following people:

Name & Relationship to Child *

My Child has Permission to Bicycle/Walk/Trolley To & From Camp Alone: *

Yes No

Medication *

My child does not take any medication on a routine basis. My child will need to take medication while at camp. List all medications your child requires during Academy hours with time and dosage below:

Medications *

Does your child have any illnesses or injuries that may affect him/her at Academy? If so, please explain below: *

Allergies: *

Dietary restrictions: we will make every attempt to work within your child’s specific dietary restrictions. *

Other helpful information Please describe any other information which may be helpful to staff (i.e., special needs, fears, behaviors, etc.). If there is any additional information about your child that you would like to communicate, please email [email protected] prior to the start of camp so we can make our staff aware of your child’s special circumstances. *

Photography Release: You authorize ETHOS Science Academy, its sponsors and affiliates, to obtain, store and/or use (without payment) any photographs, slides and/or videotapes of your child for public relations, marketing/advertising and/or internal training purposes. *

Yes

Acceptable Behavior Policy: To ensure a safe and fun environment for all, children are expected to behave in an acceptable manner and use appropriate language always. It is important to remember that there are no refunds if a child is asked to leave Academy due to unacceptable behavior. *

Yes

Comment *

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Spring 2018 Registration Form

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