2018 CBC Summer Academy

Online Registration

Summer Academy
Participant Information
First Name:  Last Name: 
Birthdate (mm/dd/yyyy):   /   /  Email: 
Address:  City: 
State    Zip Code:
Grade in 17-18: 
School: 

Parent/Guardian #1 Information
Name:  Email: 
Cell #:  Work #: 

Parent/Guardian #2 Information
Name:  Email: 
Cell #:   Work #: 

Emergency Contact Information (Other than Parent/Guardian)
Name Relationship:  
Cell #:  

Activities & Camps (Choose 1 Activity or Camp Per Week)
Week 1
June 4-8
Week 2
June 11-15
Week 3
June 18-22

Enrichment Camps
Week 1
June 4-8
Week 2
June 11-15
Week 3
June 18-22
Enrichment Camp
In the event that an Enrichment Camp is full or does not meet the minimum required,
please select an alternate Enrichment Camp.
Week 1
June 4-8
Week 2
June 11-15
Week 3
June 18-22
Alt Enrichment Camp

CBC Summer Academy Services - Payment Calculation
Select Camp and Duration:
Coupon Code: *Must use all CAPS
Week 1
June 4-8
Week 2
June 11-15
Week 3
June 18-22
1/2 Day Camper Lunch
($30)
Early Drop-Off
($30)
Late Pick-Up
($30)

CBC Summer Academy Media Release
CBC produces marketing/informational brochures, advertisements, and newsletters. Signing this form authorizes
the school to utilize photographs and/or video in future marketing materials, CBC E-news Letters, Features,
and various other types of media. These marketing materials my be used online or in print form.


CBC Summer Academy Medical/Emergency Release
Significant Medical Facts or Allergies for the above participant:
The law requires that parental permission be obtained for certain medical and operative procedures on minors.
The following consent form should be signed by the parents or guardians so that emergency medical
procedures may be promptly carried out and so that no unnecessary delays will occur with less urgent medical
and operative procedures or situations which may occur or exist. HOWEVER, NO OPERATION OTHER THAN
MINOR SURGERY WILL BE PERFORMED, EXCEPT IN AN EXTREME EMERGENCY, WITHOUT MAKING
REASONABLE EFFORT FOR PARENTS OR GUARDIANS BEING CONTACTED AND FULLY INFORMED.
PARENT/GUARDIAN SIGNATURE REQUIRED.
Please choose a treatment option:


CBC Summer Academy Transportation Release
I grant permission to Christian Brothers College High School to provide transportation for the above
participant to and from off campus activities.


Parent/Guardian Digital Signature
Parent/Guardian Name: 
Last 4 Digets of SSN: 
Birthdate (mm/dd/yyyy):