Participant Information |
First Name:
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Last Name:
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Birthdate (mm/dd/yyyy):
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Email: |
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Address: |
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City: |
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State |
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Zip Code: |
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Grade in 17-18: |
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School: |
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Parent/Guardian #1 Information |
Name: |
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Email: |
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Cell #: |
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Work #: |
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Parent/Guardian #2 Information |
Name: |
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Email: |
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Cell #: |
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Work #: |
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Emergency Contact Information (Other than Parent/Guardian) |
Name |
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Relationship: |
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Cell #: |
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Activities & Camps (Choose 1 Activity or Camp Per Week) |
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Week 1 June 4-8 |
Week 2 June 11-15 |
Week 3 June 18-22 |
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Enrichment Camps |
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Week 1 June 4-8 |
Week 2 June 11-15 |
Week 3 June 18-22 |
Enrichment Camp |
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In the event that an Enrichment Camp is full or does not meet the minimum required, please select an alternate Enrichment Camp. |
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Week 1 June 4-8 |
Week 2 June 11-15 |
Week 3 June 18-22 |
Alt Enrichment Camp |
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CBC Summer Academy Services - Payment Calculation |
Select Camp and Duration: |
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Coupon Code:
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*Must use all CAPS |
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Week 1 June 4-8 |
Week 2 June 11-15 |
Week 3 June 18-22 |
1/2 Day Camper Lunch ($30) |
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Early Drop-Off ($30) |
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Late Pick-Up ($30) |
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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. |
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CBC Summer Academy Medical/Emergency Release |
Significant Medical Facts or Allergies for the above participant:
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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.
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Please choose a treatment option:
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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. |
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Parent/Guardian Digital Signature |
Parent/Guardian Name: |
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Last 4 Digets of SSN: |
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Birthdate (mm/dd/yyyy): |
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