Early Einsteins Summer Camp 2012 Registration
Summer Camp PAID in full $200 before.
Child's Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Boy
Girl
Parents' Names
*
First
Last
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Best Number to be reached at
*
##########
School Attending
Grade Enrolled
Emergency Contacts
*
Phone Number
*
##########
Allergies/medical conditions
*
How did you hear about Early Einsteins?
Please list your 3 preferred times from the schedule
*
Mondays Only
Wednesays Only
Mon/Wed
Tues/Thur
HH
:
MM
:
SS
AM
PM
AM/PM
Mondays Only
Wednesays Only
Mon/Wed
Tues/Thur
HH
:
MM
:
SS
AM
PM
AM/PM
Monday Only
Wednesays Only
Mon/Wed
Tues/Thur
HH
:
MM
:
SS
AM
PM
AM/PM
In consideration of your accepting this registration, I, the parent or guardian of the above named student, hereby give my consent and agree to release and hold harmless Early Einsteins of Newport Beach and any of their directors or instructors from any liability, claim, or action for personal injury and/or property damage resulting from, arising out of, and/or connected to the child's participation in Early Einsteins classes or special events.I am committing to the entire session and agree to pay the full tuition. If my child is absent from a class it is my responsibility to schedule a make-up class if available.
*
I agree
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