2019 CBC Summer Academy

Online Registration

Participant Information
First Name:		Last Name:
Birthdate (mm/dd/yyyy):	/ /	Email:
Address:		City:
State		Zip Code:
Grade in 18-19:
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 3-7	Week 2 June 10-14	Week 3 June 17-21


Enrichment Camps
	Week 1 June 3-7	Week 2 June 10-14	Week 3 June 17-21
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 3-7	Week 2 June 10-14	Week 3 June 17-21
Alt Enrichment Camp

CBC Summer Academy Services - Payment Calculation
Select Camp and Duration:
Coupon Code:	*Must use all CAPS
	Week 1 June 3-7	Week 2 June 10-14	Week 3 June 17-21
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.
Permission is granted for the above participant. Permission is NOT granted for the above participant

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:
I give permission to Christian Brothers College High School for such medical operative procedures as may be deemed necessary for the above participant. This permit shall continue full force and effect until revoked in writing delivered to the Business Office of Christian Brothers College High School. If injured or ill, the above participant is NOT to recieve medical treatment until I have given my express consent.

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.
Permission for Transportation at Summer Academy is granted for the above participant. Permission for Transportation at Summer Academy is NOT granted to the above participant.

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