Boston Roundtable S.T.E.A.M. Camp at Cheshire Academy - Pre-Registration Form

Part One: Student Information

* Indicates required field

1. First Name: *

2. Last Name: *

3. Age *

5. Date of Birth: *

6. Grade: *

4. Gender: *

If "Other," Please Specify: *

Part Two: Location

7. Address: *

Line 1

Line 2

City

State

Zip Code

Country

8. Family Email: *

9. Home Phone: *

Part Three: Family Information

10. Guardian 1 Name: *

12. Guardian 1 Cell Phone: *

11. Guardian 1 Relationship to Student: *

13. Guardian 1 Work Phone: *

14. Guardian 1 Email: *

15. Student Emergency Contact? *

16. Guardian 2 Name: *

18. Guardian 2 Cell Phone: *

17. Guardian 2 Relationship to Student: *

19. Guardian 2 Work Phone: *

20. Guardian 2 Email: *

21. Student Emergency Contact? *

Part Four: Emergency Information

Note: If you have already indicated one or more guardians as the emergency contact, you may leave that information blank here

22. Emergency Contact Name: *

24. Emergency Contact Email: *

23. Emergency Contact Relationship to Student: *

25. Emergency Contact Cell Phone: *

26. Please indicate any allergies your child has (i.e. medications, food, bee stings, etc): *

27. In the unlikely event of a medical emergency requiring medical attention, do you grant permission for the camp nurse or physician to attend to your child? *

Yes No

Part Five: Certification of Accuracy

Certification: *

By checking this box, you certify that all information in this form is true and correct to the best of your knowledge.

Additional Comments or Questions (optional): *

Submit

S.T.E.A.M. Camp​at Cheshire Academy​​Pre-Registration Form

Part One: Student Information

Part Two: Location

Part Three: Family Information

Part Four: Emergency Information

Part Five: Certification of Accuracy

S.T.E.A.M. Camp
at Cheshire Academy

Pre-Registration Form