Registration Sample – do not use

$1,000.00

Student Info

Information about the student

Student's name. First and last. Required

Student's date of birth, required.

Student's age at beginning of camp/event.

Gender student identifies with.

Street address where student resides. Be sure to include city, state, and zip code.

Student's phone number or a number we can call with event/camp related information/updates.

Student's email address, or one we can use for event/camp related information/updates

Legal Guardian Information

legal guardian name (first and last)

legal guardian phone number if different than one listed for student above.

legal guardian address if different than one listed for student above

Ethnicity

We collect this data for Federal Grants and demographic information.

Tuition Assistance and Reduced Free/Lunches

Please check the boxes if you qualify for either or both of the following:

In case of emergency please contact:

Release and Waiver of Liability and Hold Harmless Agreement

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

Initials

Initials

Initials

Initials

Type your name if you agree. This will act as your electronic signature.

Subtotal:

Add-ons total:

Total:

Category:

Description

This is a filler space for what Kaleidoscope Discovery Center will put to describe what the person is registering for.