2021 HS Enrollment 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:*General Engineering for High School (July 5-9)General Engineering for High School (July 12-16)General Engineering for High School (July 19-23)General Engineering for High School (July 26-30)Grade placement based on 2021-2022 school year.Participant's Name:* First Last Participant's Preferred Name:*Please type exactly how participant's name should be printed on their name tag.Participant's Birthdate:* Date Format: MM slash DD slash YYYY Participants grade NEXT year (2021-2022):*9th10th11thParticipant's anticipated school NEXT year (2021-2022):*Ethnicity:* African American Asian Caucasian Hispanic Native American Pacific Islander Other Prefer not to disclose Parent or Guardian Name:* First Last Parent or Guardian 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 Daytime Phone:*Parent or Guardian Cell Phone:*Parent or Guardian Email:* Enter Email Confirm Email OPTIONAL: Please include a second parent/guardian's contact information (name, phone, email) if you would like them kept on file as well.How did you hear about our program?*We previously attendedA family member was a previous attendeeA friend told us about the programMy child's teacher told us about the programAn electronic flyer through my child's school (ex. PeachJar)I 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.In case of emergency, primary contact is:* First Last Relation to participant:Primary contact phone:*In case of emergency, secondary contact is:* First Last Relation to participant:Secondary contact phone:*Program Fees*Tuition ($395)Price per camperTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Product NameProduct Name
