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Random Math Summer Camp Registration

Camper Information

* Indicates required field

Name *

First

Last

Entering Grade in Fall *

School *

Birth Date (mm/dd/yyyy) *

Parent Information :

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Additional Email *

Preferred Phone Number *

Alternate Phone Number *

Emergency Contact Information :

Name *

First

Last

Relation *

Work Phone Number *

Cell Phone Number *

Doctor's name *

Doctor's Phone Number *

Additional Information :

Authorized Person Pick up if any (in addition to parents and emergency contacts) *

Does your child have any allergies and/or intolerances to food, medication or any other substances? What are the symptoms and action to be taken if any? *

How did you hear about us *

Web Search Friends and Family Other

Camp Selection :

Please select the session that you would like to attend *

Number Theory (Jun 13 - Jul 01) - Full [Waitlist] Algebra (Jul 06 - July 22) Geometry ( July 25 - Aug 12)

Do you require extended care ( 5 pm - 6 pm) *

Yes No

ACKNOWLEDGEMENT OF TERMS

Random Math Camp is a fee-for-service program based on confirmation enrollments and secured deposits. In order to reserve your child(ren’s) spot, full payment must be received for each child and session you are registering for. If the session(s) you are trying to register for has filled, your child(ren) will be placed on the wait list in the order that the registrations are received.
Parent or Guardian - Your signature below indicates compliance with Random Math summer camp regulations.

Parent/Guardian Signature *

Date (mm/dd/yyyy) *

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