Selected Camp:

Camp Date: July 11-13
Camp Location: Kerbey Lane Café, 13435 Hwy 183 N Ste. 415
Student Age Group: Ages 13-18
Camp Cost: $325.00 (plus $25 lunch fee)

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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