Name: Future City Junior Camp (July 18 - 22), 4th – 5th grades, Rolla
SKU: 9402
Price: 100.00 USD
Availability: OutOfStock

Description

Future City Jr.
4th – 5th grades

July 18 -22
8:30 am – 11:30 am
Rolla

Specially designed for rising 4th and 5th grade students interested in how cities work! Explore the importance of city design by building a model with a moving part, by virtual design using Sim City software and by area field trips. This camp is designed to give younger students an opportunity to learn more about national Future City Competition.

Maximum Registration: 8 students

IMPORTANT: Before your registration can be considered complete, you must fill the registration form below. Please be sure the number of students you’re registering on the form matches the number you’re paying for.

Registration Form - Future City Jr. July 18 - 22

How many students are you paying for and registering at this time? *

Student #1

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #2

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #3

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #4

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #5

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #6

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #7

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

Student #8

Student Name *

Student Name

First

Last

Student Birthdate *

Student Age (at time of class/event) *

Student Phone *

Is the student's phone number the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's number in the next section)

Student Address *

Student Address

City

State

Zip/Postal

Country

Is the student's address the same as their legal guardian's? *

Yes, it's the same

No (you'll be asked to enter the legal guardian's address in the next section)

Legal Guardian Name *

Legal Guardian Name

First

Last

Legal Guardian Phone *

Legal Guardian Address *

Legal Guardian Address

City

State

Zip/Postal

Besides the legal guardian listed above, is there anyone else you 'd like to list as an emergency contact?ional person listed as well? *

Yes, there is someone else,. I'll list them below.

No, just the legal guardian listed above is fine

Additional Emergency Contact Name *

Additional Emergency Contact Name

First

Last

Additional Emergency Contact Relation to Student *

Additional Emergency Contact Phone *

Does your student have any allergies we should be aware of? *

Yes

Allergies *

List any allergies your child has and please list the reactions to those allergies:

Does your child have an EpiPen? *

Yes

Is your child able to able to administer the EpiPen themselves? *

Yes

Special accommodations or anything else we should know

List any special accommodations needed for your child or anything else you feel is beneficial for us to know. Or feel free to leave blank if there are none.

The Kaleidoscope Discovery Center

PLEASE READ CAREFULLY. THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.

Paragraph

Type your name if you agree with the waiver of liability and hold harmless agreement as stated above: *

We may want to use photographs of your child in print or online material designed for news, informational or educational purposes related to The Kaleidoscope Discovery Center. Is this okay with you? *

Yes, you're welcome to use photographs of my child

No, I do not grant permission for you to use photographs of my child

Don't forget to "Add to Cart"

Your registration won't be complete unless you do this

If you are human, leave this field blank.

Future City Junior Camp (July 18 – 22), 4th – 5th grades, Rolla

Description

Registration Form - Future City Jr. July 18 - 22

Student #1

Student #2

Student #3

Student #4

Student #5

Student #6

Student #7

Student #8

The Kaleidoscope Discovery Center

Don't forget to "Add to Cart"

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