BRAINY BLAST SUMMER CAMPREGISTRATION Summer Camp Form Date(Required) Number of ChildrenPlease enter a number from 1 to 4.Name of Child 1(Required) First Last Age 1(Required)Date of Birth 1(Required) Allergies 1School Attending 1Name of Child 2(Required) First Last Age 2(Required)Date of Birth 2(Required) Allergies 2School Attending 2Name of Child 3(Required) First Last Age 3(Required)Date of Birth 3(Required) Allergies 3School Attending 3Name of Child 4(Required) First Last Age 4(Required)Date of Birth 4(Required) Allergies 4School Attending 4Parent or Guardian Contact InformationName of Parent or Guardian First Last Email(Required) Cell Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact InformationName Name Relationship HomeCell(Required)Which Special Services are being received at school? None IEP/ClassificationMedicationHow does your child learn best? Do you have any suggestion for your child's tutor?PaymentRegistration FeesSelect Week(s) June 8 - 12: June 15 - 18: June 22 - 26: June 29 - July 3: July 6 - 10: July 13 - 17: July 20 - 24: July 27 - 31: Initial Fee Price: $0.00 Initial fee of $225 for the first child and $200 for each additional children is due upon checkout. Additional week(s) payment will be assessed later.Youth XS Quantity Price: $15.00 Quantity Youth S Quantity Price: $15.00 Quantity Youth M Quantity Price: $15.00 Quantity Youth L Quantity Price: $15.00 Quantity Youth XL Quantity Price: $15.00 Quantity Adult XS Quantity Price: $20.00 Quantity Adult S Quantity Price: $20.00 Quantity Adult M Quantity Price: $20.00 Quantity Adult L Quantity Price: $20.00 Quantity Adult XL Quantity Price: $20.00 Quantity Adult XXL Quantity Price: $20.00 Quantity Adult XXXL Quantity Price: $20.00 Quantity Consent(Required) I hereby certify that the information provided on this application is true and correct. If any of this information changes, I will notify Vienna Adventist Academy and update my information.SignatureYour NameYour NameYour NameYour NameDate Credit CardCard Details Cardholder Name Convenience Fee $0.00 Coupon Total
