Registration Form 2024 Camper InformationChild's Name(Required) First Last Preferred Nickname(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Current Age(Required) Gender(Required) Female Male Non-binary I choose not to say Parent/Guardian InformationParent/Guardian Name 1(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Parent/Guardian Name 2(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Emergency Contact Information (must be different from Parent/Guardian listed above.)Emergency Contact 1(Required) First Last Cell Phone(Required)Relationship to Camper/Child(Required) Emergency Contact 2(Required) First Last Cell Phone(Required)Relationship to Camper/Child(Required) Person/s Authorized to Pick Up Camper/ChildName 1(Required) First Last Relationship to Camper/Child(Required) Name 2(Required) First Last Relationship to Camper/Child(Required) Medical InformationList allergies or intolerance to food, medication, or any other substance. (Put n/a if not applicable.)(Required)If an allergic reaction occurs, please list steps to relieve reaction. (Put n/a if not applicable.)(Required)Please list any chronic physical, behavioral or psychological problems, pertinent developmental information, any special accommodations needed. (Put n/a if not applicable.)(Required)Child's Physician's Name(Required) First Last Physician's Phone(Required)Emergency Medical Authorization: I give Flexible Thinkers, LLC permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a certified staff member of the Flexible Thinkers. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize Flexible Thinkers to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may only cover those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts. (Please put initials below.)(Required) I/we will be responsible for payment of medical expenses. Medical treatment costs are covered by medical insurance provider. Policy Number:(Required) Parental Agreements: 1) Flexible Thinkers LLC agrees to notify the parent/guardian whenever the child becomes ill and the parent/guardian will arrange to have the child picked up as soon as possible if requested by Flexible Thinkers LLC. 2) The parent/guardian agrees to inform Flexible Thinkers within 24 hours or the next business day after his child or any members of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. (Please put initials below.)(Required) Cancellation Policy: Flexible Thinkers LLC has a non-refundable deposit of $150 which is applicable to the registration fee. Your child's spot is not guaranteed until the deposit has been paid. If the entire registration fee has been paid, and a cancellation is made two weeks before the start of camp session, your payment will be returned less the non-refundable deposit of $150. If fees have been paid but cancellation is made less than two weeks before the start of camp, your payment will be returned less $200 (non-refundable deposit of $150 plus a $50 cancellation fee). If fees have been paid but cancellation is made after the camp begins then no refund will be given. If this transaction fails to close for any reason, the non-refundable fee shall remain the property of Flexible Thinkers LLC. (Please put initials below.)(Required) I am registering my child for the following camp session/s:(Required) July 15-18 July 22-25 Both sessions I will be invoiced $325 for 1 camp session. If I register my child for 2 camp sessions or I register more than one child, I will get a 10% off discount. If my child is a current Flexible Thinkers' client, I will get a 5% off discount for 1 camp session.(Required) I agree. I do not agree. My preferred form of payment is – (Note: A processing fee of 3.5% will be added to credit or debit card payments.)(Required) Credit or Debit Card Personal Check Money Order Cashier’s Check Other I understand that my child needs to be toilet-trained to participate in camp. (Please put initials below.)(Required) I understand and agree to the Emergency Medical Authorization, the two (2) Parental Agreements, and the Cancellation Policy outlined above. (Please put initials below.)(Required) By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. Please put a slash between your name, e.g., /Jane Doe/(Required) How did you learn about us?(Required) Social Media (Facebook, Instagram) Google Search Personal Referral School Personnel Community Event Medical Provider Flyer/brochure/leaflet from a local business We are current Flexible Thinkers clients Other CAPTCHANameThis field is for validation purposes and should be left unchanged.