Learning Lab Program Online Registration

Registration

PLEASE READ: Welcome to the Boys Will Be Boys Summer Camp 2023. Old and New Customers MUST fill out his form for 2023. If you fill out this form and do not select your classes you need to log back and select your camp sessions. PLEASE DO NOT MAKE ANY PAYMENTS WHEN REGISTERING! YOUR CREDIT CARD WILL BE CHARGED AT A LATER DATE.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier*

Authorized Pick Up & Number*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work # *

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work #

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Parent Email*

T-Shirt Size*

School Currently Attending*

Grade Level for 2023-2024*

Special Needs/Disabilities/Fears

Allergies/Medications

Medications (Leave blank if NONE)

Primary Doctor & Number*

Camp T-Shirt Size?*

Additional Shirts ($10 each )

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Parent Email*

T-Shirt Size*

School Currently Attending*

Grade Level for 2023-2024*

Special Needs/Disabilities/Fears

Allergies/Medications

Medications (Leave blank if NONE)

Primary Doctor & Number*

Camp T-Shirt Size?*

Additional Shirts ($10 each )

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Parent Email*

T-Shirt Size*

School Currently Attending*

Grade Level for 2023-2024*

Special Needs/Disabilities/Fears

Allergies/Medications

Medications (Leave blank if NONE)

Primary Doctor & Number*

Camp T-Shirt Size?*

Additional Shirts ($10 each )

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Parent Email*

T-Shirt Size*

School Currently Attending*

Grade Level for 2023-2024*

Special Needs/Disabilities/Fears

Allergies/Medications

Medications (Leave blank if NONE)

Primary Doctor & Number*

Camp T-Shirt Size?*

Additional Shirts ($10 each )

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

Cell #*

Additional Info

Parent Email*

T-Shirt Size*

School Currently Attending*

Grade Level for 2023-2024*

Special Needs/Disabilities/Fears

Allergies/Medications

Medications (Leave blank if NONE)

Primary Doctor & Number*

Camp T-Shirt Size?*

Additional Shirts ($10 each )

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

Membership Type*

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

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