Summer Science Camp Registration

Name of Camper:*
First Last
Parent/Guardian:*
First Last
Address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Email Address:*
Day Phone:*
Evening Phone:*
Date of Birth:*
MM
DD
YYYY
Fall 2014 Grade Level:*
Gender:*
- Male
- Female
School Name:*
Emergency Contact:*
Emergency Contact Phone:*
Does the camper have any special needs with respect to diet, health, or medication?
Please Provide Details
2014 Science Camp Schedule:*
- Discovery Camp: June 24-27, 2014 Ages 8-11
- Explorer Camp: July 8-11, 2014 Ages 12-14
- Scholar Camp: July 22-25, 2014 Ages 15-18
Please Select One
Shirt Size:*
Camp Registration
Price: $350.00
Parent/Guardian Signature:*
*By typing your name in above, you and your child accept all responsibility and agree to hold harmless and indemnify SERI and its employees against any liability, including all cost of expenses, which may result on account if any injury may occur with your child during camp hours. You and your child also understand and agree that photographs may be taken during camp that may later be used for marketing purposes.
Parent/Guardian Signature Date:*
MM
DD
YYYY

Total camp tuition: $350 includes lunch, snacks, t-shirts, field trips and all camp supplies. Payment is due in full at time of registration (payment plans are available on an as need basis). Registration closes once camps reach capacity.
How would you like to pay?
- Credit Card via PayPal
- Check
Please mail checks on or before the start date of camp to:
The SERI
Attn: Taylor DeLaura
9005 Grant Street
Suite 100
Thornton, CO 80229