2021 Middle School Spring Break Camp: Session II: April 12-16 Registration

Registrant Name*

First Last

Relation of Registrant to Attendee(s)*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

I would like to register:

One Attendee
Two Attendees
Three Attendees

A discount of 10% is automatically applied to the cost of registering multiple children in the same household.

Attendee Information

Attendee Name*

First Last

Gender*

Female
Male
Other

Birth Date*

Grade*

School Name*

Attendee 2

Attendee 2 Name

First Last

Email 2

Address 2

Street Address Address Line 2 City State ZIP Code

Gender 2

Female
Male
Other

Grade 2

Birth Date 2

School Name 2

Attendee 3

Attendee 3 Name

First Last

Email 3

Address 3

Street Address Address Line 2 City State ZIP Code

Gender 3

Female
Male
Other

Grade 3

Birth Date 3

School Name 3

Parent/Guardian Information

Parent/Guardian 1 Name

First Last

Parent/Guardian 1 Relationship

Parent/Guardian 1 Phone

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Relationship

Parent/Guardian 2 Phone

Accommodations and Allergies

Please explain any special accommodations that your child may need:

Does your child have any allergies?*

Yes
No

Please explain:

Does your child have any medical or behavioral needs which will require special attention from our staff?*

Yes
No

Please explain:

Does your child take any medications?*

Yes
No

Do you understand that your child's participation in this MEarth program will require full compliance with Covid-19 related safety measures, protocols, and communications, and that lack of compliance may result in the termination of their participation without refund of registration fees?*

Yes
No

Please explain:

Waiver

Waiver Statement:*

I understand that checking the Terms & Conditions box below, and clicking the "Continue" button acknowledges that I have read, understand, and agree to the terms and conditions outlined herein as a condition of my child's participation in the MEarth program for which I am registering them. I further understand that checking the Terms & Conditions box below and clicking the registration “Continue” button has the same force of law as my original signature. I understand that I am not obligated in any way to make such agreement, except as a prerequisite to my child's participation in this program. By checking the box below and clicking the "Continue" button, I agree that all information submitted in this form is true and accurate to the best of my knowledge.

I agree

Payment

Total

$0.00

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