2017 Spring Break Camp Registration Form

Dear Parents and Trainee (Applicant):

Thank you for your interest our 2017 Spring Break Camp operating at Amana Academy. Please fill out this application form completely. Your child will not be registered until the registration fee and Spring Break payment are made.

Parent\Guardian Name:
Additional Parent/Guardian Name:
Parent's E-mail:*
Primary Contact Phone:
Secondary Contact Phone:
Youth's Name:
Youth's E-mail:
Student's Age:*
School Attending:*
Second Child:
Second Child E-mail:
Second Child's Grade
Second Child Age:
School Attending:(1)
Third Child:
Third Child E-mail:
Third Child Age:
School Attending:(2)
Third Child's Grade:
Emergency Contact 1 Info:
Emergency Contact 1 Phone:*
Emergency Contact 2 Name:
Emergency Contact 2 Phone:
Authorized Person for Pickup:
Primary Authorized Person for Pickup:
Primary Relationship :
Secondary Authorized Person for PickUp:
Relationship :

Kids Tech U Spring Break 2017 Pictures & T-Shirts

The Spring Break trainees will take a group picture on the last day.    Everyone will have their Kids Tech U Spring Break T-shirts.   Please purchase your t-shirt as soon as you register to make sure your child has their t-shirt and there is no delay.

T-Shirt #1 Size:
T-Shirt #2 Size:
T-Shirt #3 Size:

By�typing your full�name below, you understand and accept Kids Tech U program policies; and agree to comply with its terms.���� If you filled out a hard copy from the school , you may sign and email forms, or send to school with your child. Please email or call us to notify us that your child will be attending; if you send it to school with them on day of program.

Registration Fee ($20 per child)*
Camp Fee ($150 per Child )*
T-shirt ($18 per Child )*
Total Due:
Signature Name:*
Date of Signature:*
Word Verification: