Registration Form 2014

  1. Which campus will participant attend? (*)
    Please select one
  2. If registering for the Sandy Springs campus, which SESSION will participant attend? (*)
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  3. Participant FULL Name(*)
    Please type your child full name.
  4. Gender(*)
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  5. Participant's DOB(*)
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  6. Age (MUST be 6yrs old OR have completed Kindergarten with school records for proof.)(*)
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  7. CURRENT Grade Level (2013-14 School Year) (*)
    Please select one
  8. School Name (*)
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  9. T-shirt Size (1 free camp shirt is included in registration fee)(*)
    Please select one
  10. Has the participant attended our camp before? If so, which year and campus? Select all that apply.(*)







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  11. Guardian-1 Full Name(*)
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  12. Guardian-1 Relation to Participant(*)
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  13. Guardian-2 Full Name(*)
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  14. Guardian-2 Relation to Participant(*)
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  15. Address(*)
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  16. City(*)
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  17. Zip(*)
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  18. Home Phone
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  19. Guardian-1 Cell Phone(*)
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  20. Guardian-1 Work Phone(*)
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  21. Guardian-2 Cell Phone(*)
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  22. Guardian-2 Work Phone(*)
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  23. E-mail(*)
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  24. Emergency Contact Information & Persons Authorized to Pick Up Child

  25. Full Name & Relation of 1st Emergency Contact(*)
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  26. Phone or Cell(*)
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  27. Full Name & Relation of 2nd Emergency Contact(*)
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  28. Phone or Cell(*)
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  29. Sibling Info (If attending camp as well)

  30. Will there be siblings attending camp at the same time as participant? If so, please list their information below.(*)
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  31. Sibling(s) Name(s) & T-shirt Size(s)
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  32. Sibling(s) Age(s)
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  33. Sibling(s) Grade(s)
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  34.  
  1. Medical Information

  2. Allergies(*)
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  3. Present Medical Conditions(*)
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  4. Regular Medications Being Taken?(*)
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  5. Physician name(*)
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  6. Physician phone(*)
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  7. Insurance Carrier
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  8. Permission for Treatment, Participation, & Photo/Video Waiver

    My permission is granted for a representative of Young Masterminds of Atlanta, Inc. to obtain necessary professional medical attention in case of sickness or injury to my child. I understand that I am responsible for any related expenses incurred for treatment. I also grant permission for Young Masterminds of Atlanta’s chosen transportation services to transport my child to and from the program site for scheduled events. I also understand that it is my parental responsibility to inform YMA directors of any changes in the information listed on the registration form.
  9. Parent Signature for Permission to Treat, Participate, & Photo/ Video Waiver(*)
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    By typing your name, you agree that it legally serves as your electronic signature and authorization of the above waiver.
  10. Refunds and Licensing Disclaimer

    I understand that there are no refunds issued for registration and/or tuition fees. I understand that Young Masterminds of Atlanta, Inc. is not licensed by Bright from the Start. This organization has filed and is approved to operate as an exempt organization in the State of Georgia.
  11. Parent Signature for Refunds and Licensing Disclaimer(*)
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    By typing your name, you agree that it legally serves as your electronic signature and authorization of the above disclaimer.
  12. Liability Waiver

    I grant permission for Young Masterminds of Atlanta’s chosen transportation services to transport my child to and from the program site for scheduled events. I also understand that it is my parental responsibility to inform YMA directors of any changes in the information listed on this form. I, the undersigned, do hereby verify that all of the above information is correct and I do hereby release and discharge Young Masterminds of Atlanta, and all related parties, from any and all claims, demands, actions or causes of action, past, present and future arising out of any damage or injury while participating in this summer program and/or traveling from program site to destination sites.
  13. Parent Signature for Liability Waiver(*)
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    By typing your name, you agree that it legally serves as your electronic signature and authorization of the above waiver.
  14. Date(*)

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  15. How did you hear about our program?(*)
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  16. I am interested in volunteering as a chaperon, reading buddy, parent counselor, or to fill in where needed.
  17. Additional Notes
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  18. Payment MUST be received (via Paypal) in order for participant's spot to be reserved.

  19. Registration fee (Includes 2.8% transaction fee per Paypal)(*)
    Please choose one
  20. If you would like to donate, please add amount here:
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  21. Total:
    0.00 $USD
  22.   
  23. Please only click "submit" once. Loading may take up to 30 seconds as it is sending the registration form and transferring you to Paypal for payment.