2020 Enrollment Form HS Please submit a separate form for each additional child. If you have any questions about enrollment, or our program, please email Jennifer at jennifer@cynosurelearning.com or call 980-500-9345. We are looking forward to having your family with us this summer! I would like my child to attend the following program*July 6-10 DO NOT SIGN UP. WEEK IS FULL. EMAIL FOR WAIT LIST.July 20-24 DO NOT SIGN UP. WEEK IS FULL. EMAIL FOR WAIT LIST.Grade placement based on 2020-2021 school year.Participant's Name* First Last Participant's Preferred Name*Please type exactly how participant's name should be printed on their name tagParticipant's Birthdate* Date Format: MM slash DD slash YYYY Participants grade NEXT year (2020-2021 school year)*9th10th11thParticipant's anticipated school NEXT year (2020-2021 school year)*Ethnicity* African American Asian Caucasian Hispanic Native American Pacific Islander Other Prefer not to disclose Parent or Guardian 1* First Last Parent or Guardian 1 Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent or Guardian 1 Daytime Phone*Parent or Guardian 1 Cell Phone*Parent or Guardian 1 Email* Enter Email Confirm Email Parent or Guardian 2 Name First Last Parent or Guardian 2 Address (if different than above) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent or Guardian 2 Daytime PhoneParent or Guardian 2 Cell PhoneParent or Guardian 2 Email Enter Email Confirm Email How did you hear about our program?*A friend told us about the programWe previously attendedA sibling was a previous attendeeMy child's teacher told us about the programAn electronic flyer through my child's school (ex. PeachJar)In person event (ex. camp fair, open house, science fair...)Printed publication (ex. Charlotte Parent)Social media postsI saw the link on NCSU's websiteInternet searchOtherParticipant's t-shirt size*Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult Extra LargeYouth t-shirt sizes run small. We are unable to guarantee shirts to those who register after June 15th.Please provide us with any food allergies or additional medical information you would like to share regarding your child. This information will be communicated directly with your child's team lead and assistant team lead. If applicable allergies or medications change, please contact Jennifer at jennifer@cynosurelearning.com to update. NOTE: WE ARE UNABLE TO HONOR GROUP REQUESTS. THIS SPACE IS FOR MEDICAL INFORMATION ONLY.Please choose one of the following*In the event of any medical emergency, I authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that Queens University of Charlotte personnel deem necessary for my/my minor child’s safety and protection.In the event of any medical emergency, I DO NOT authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that Queens University of Charlotte personnel deem necessary for my/my minor child’s safety and protection.In case of emergency, primary contact is* First Last Primary contact phone*In case of emergency, secondary contact is* First Last Secondary contact phone*During the week photographs and videos may be taken of your child by staff affiliated with the NCSU's Engineering Camp Charlotte. This media may be used for promotional purposes and in other university publications. At times, members of the news media or others associated with documenting our summer programs may also be present to take pictures or video.*I give my permission for my child to be photographed or videoed while participating in NCSU's Engineering Camp Charlotte.I DO NOT give my permission for my child to be photographed or videoed while participating in NCSU's Engineering Camp Charlotte.Program Fees*Tuition ($395)Tuition + Lunch ($447)Price per camperTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Product NameProduct Name
