STEM & Arts Program Claysburg- Student Registration 2019

Claysburg Education Foundation

Parent/Guardian phone number

T Shirt Size *

Emergency Contact #2 Phone Number *

Emergency Contact #1 Phone Number *

Grade entering for 2020-2021 School Year *

I give authorization to the Claysburg Education Foundation & the Claysburg-Kimmel School District to photograph my child and use any photo and/or video for publishing via local news publications, CKSD or Claysburg Education Foundation website or social media platforms. *

Yes

Parent/Guardian Name *

Comments/Questions:

School District Currently Attending *

Email: *

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Emergency Contact Name #2 *

Student's Name *

Emergency Contact Name #1 *

Summer STEM & Arts will be held on the following dates: June 15-18, July 6-9, July 20-23. If there are any dates they will NOT be able to attend, please indicate below. If attending all dates, please type ALL *

To ensure this is a beneficial and worthwhile experience as well as to maintain the safety of all students attending the Summer Stem and Arts, if a student is found to be engaging in horseplay, being a distraction to others, not following directions, or otherwise endangering themselves or another student their parent or guardian will be immediately notified and the student will be removed from the program. *

I have read the above statement, understand and agree.

Street Address *

2020 Claysburg's STEM and the Arts

June 15-18, July 6-9, July 20-23

Registration Is Open to Claysburg Kimmel Students Only

Registration will open to all area students on April 16

Must be entering Grades 5-12 for 2020-2021 School Year

Limited Seats!

Last Day to Register-May 22, 2020

PAYMENTS:

You can make a payment for each registration by clicking 'Buy Now' below. If you wish to pay with a Debit/Credit Card, first login to Paypal. Under the 'Pay With' section you can add a credit/debit card and then select the card.

Please List Any Allergies or Medical Issues we should be aware of. If none, enter None *

City, State & Zip Code *

Phone: 814-239-2901

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