Registration
3 openings left in this event!
Already a customer? Click here to login.
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Father
Guardian
Mother
Other
Parent
Home Phone:
Cell #:
Work #:
Email:
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Emergency Contact Information
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Student Email:
School:
Grade Level:
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE):
Allergies (Leave blank if NONE):
Medications (Leave blank if NONE):
Primary Doctor:
Additional Information:
Release of Liability
(Show-Hide Details)
As the legal parent or guardian, I release and hold harmless Freckled Frog Learning Center its owners and operators from any and all liability, claims, demands, and causes of action whats so ever, arising out of or relating to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control of Freckled Frog Learning Center, its owners and operators or in route to or from any said premises. I/we accept that, correct teaching may involve the use of touch by the Freckled Frog faculty members as a necessary tool to correct placement, lines and positions and by signing below I/we authorize and agree to these teaching practices.
I've read the above and agree.
Consent of Photography/Video
(Show-Hide Details)
In signing this form, I consent to and authorize the use and reproduction by Freckled Frog, of any and all photographs, recordings, videotapes, and/or other reproductions of likeness of the student's person or characteristics without compensation to the student.
I've read the above and agree.
Medical Emergency
(Show-Hide Details)
The undersigned gives permission to Freckled Frog, its owners and operators to seek medical treatment for the participation in the event they are not able to reach a parent or guardian. I hereby declare and physical/mental problems, restrictions, or conditions and/or declare the participant to be in good physical and mental health.
I've read the above and agree.
$50.00 Non-refundable deposit
(Show-Hide Details)
A $50.00 Non-Refundable deposit to hold your spot will be charged to your credit card when you complete the registration. The $50.00 will go towards the final balance which will be billed and charge 3 weeks before camp starts.
I've read the above and agree.
Enter your Full Name:
*
Other Questions/Comments:
Credit Card Verification:
Card Number:
*
Visa
Mastercard
Name as it appears on card:
*
Nickname:
Card Expiration Month:
*
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
*
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
*
Please Wait...