The Cornerstone School -> Connect -> Cornerstone Day Camp -> Day Camp Registration
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2018 Cornerstone Day Camp Registration
Child's First Name
Child's Last Name
Birthdate*
(mm/dd/yyyy)
Gender*
 Boy  Girl
Current Grade Level
School attending in fall
Contact Information:

Parent's Name*
First
Last
Home Phone*
Cell
Email *
Address Information

Address Line 1*
Address Line 2
City*
State*
Zip Code*
(ex. 06108 or 06108-0809)
Session(s) Selection
(Weeks 1 - 3 Full Payment is due by May 25th & Weeks 4 -5, Full Payment is due by June 15th.)

Session 1 - We Got Chemistry - June 4th-8th
None
Full Pay $150
Session 2 - Construction & Destruction - June 11th-15th
None
Full Pay $150
Session 3 - Food Science - June 18th-22nd
None
Full Pay $150
Session 4 - Under the Scope - June 25th-29th
None
Full Pay $150
Session 5 - Amazing Body - July 9th-13th
None
Full Pay $150
Session 6 - Robots & Rockets - July 16th-20th
This session is full.  We offer a STEM camp July 23 - 27.  Once you complete your registration, you will be directed to our STEM camp page.
None
Form Total: $0.00
Health Information / Emergency Contacts
________________________________________________________________________________________________________________________________
List any allergies or other current health issues below.  Include any physical, mental or emotional problems.  Provide any information concerning this child's health, habits or welfare of which the camp staff should be aware:
Child's Physician
Physicians Phone Number
Will the camper require medication while at camp? 
No
Yes
If "Yes" please read the "Important Information Regarding Medications" sheet on the left hand side of the page and complete the REQUIRED " Authorization for Administration of Prescription Medication" for EACH medication.
 
Please list any medications your child will be required to receive while attending camp:
Three (3) additional emergency contacts (REQUIRED)
(1)  Emergency Contact, Relationship and Phone Number
(2)  Emergency Contact, Relationship and Phone Number
(3)  Emergency Contact, Relationship and Phone Number
Please provide sunscreen for your camper(s) the week they attend camp.  In the absence of camper's personal supply, sunscreen will be available at camp.  Selecting "yes" is authorizing the use of camp supplied sunscreen.
Yes
No
Parent Authorization
As the parent or legal guardian, I have described all medical conditions which could limit my child from being able to fully enjoy and experience Cornerstone's activities.  The person herein described has permission to engage in all prescribed camp activities except as noted to me.  I hereby give permission to the physician selected by the school teacher or Cornerstone staff to order x-rays, routine test, and treatment for the health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the school teacher or Cornerstone Staff to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. It is expressly understood and agreed that Cornerstone shall not be responsible or legally liable for any losses of personal property or for any bodily injuries, or the results thereof, incurred and suffered by the applicant or in connection with any activities or programs, unless such loss or injury results directly from the negligent or willful act of an employee of Cornerstone acting within the scope of his/her employment.  I grant permission for image and likeness (i.e. photo, name, quotes) of my child to be used in publications by the institute. 
 
By signing your full name below you are agreeing all the information above is true and accurate. Please type your full name below as this will serve as an electronic signature.
 
Name on Card*
Credit Card Type*
Card Number*
Expiration Month*
Expiration Year*
CCV*
Address Line 1*
Address Line 2
City*
State*
Zip Code*
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