Brainiacs Science Discovery Center - Summer Camp Registration

(PLEASE PRINT THIS FORM AND MAIL OR BRING TO THE CENTER)
We accept Visa and Mastercard payment


SESSION	AGE GROUP	DATES

CHILD’S NAME:

ADDRESS:

CITY , STATE, ZIP:

EMAIL ADDRESS:

MOTHER/GAURDIAN:

PHONE:

(please include home, cell, and work number)

FATHER/GAURDIAN:

PHONE:

(please include home, cell, and work number)

ALLERGIES & MEDICAL CONDITIONS WE SHOULD BE AWARE OF:
PLEASE LIST OR WRITE NONE.

PHYSICIAN’S NAME & PHONE NUMBER:

PLEASE READ AND SIGN BELOW:
I have read and agreed to Brainiacs Science Discovery Center Summer Camp Policies.
PARENT/GAURDIAN SIGNATURE

(PLEASE PRINT THIS FORM AND MAIL OR BRING TO THE CENTER)
We accept Visa and Mastercard payment