Selected Camp:

Camp Date: June 14-18
Camp Location: Waterloo Ice House @ 360
Student Age Group: Ages 12-18
Camp Cost: $325.00

Please take care to fill out this form completely as this is the registration form for the summer camp. You will sign the original on the first day of camp.

*Required

Student Information:

First name of child*

Last name of child*

Birth date of child*

School District*

Parent Information:

Adult responsible for registering
child (first and last name)*

Mother First Name*

Mother Last Name*

Father First Name*

Father Last Name*

Contact Email*

Confirm Contact Email*

Other Email

Home Phone* (XXX-XXX-XXXX)

Mother's Cell Phone* (XXX-XXX-XXXX)

Father's Cell Phone* (XXX-XXX-XXXX)

Phone number and name to contact
during camp* (XXX-XXX-XXXX)


Emergency contact other than parent
during camp* (XXX-XXX-XXXX)


Home Address*



Zip Code*

Name on Payment Form*



Where did you learn about our camp?
Austin Family
Parent Wise
Austin Family Camp Fair
Round Rock Camp Fair
Georgetown Camp Fair
Friends
Family
Returning Camper
Other

Considerations*
Please let us know about any considerations we should be aware of about your child; nutritional, emotional, etc., which will assist us in providing a positive and comfortable experience at Entrepreneur Camp: State none if applicable

Photography*
May we use still photos and /or video clips including your child in future promotional or instructional materials (with no identifying names)?
Yes No


Responsibility*
I agree that the adult responsible for delivering and picking up my student will come to the classroom to sign them in and sign them out each day.
Yes No


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