Summer Camp Registration Form

Lowery Institute’s Rising Change Agent Servant Leadership Camp Registration Form
Camper Full Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Gender*
School Name
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number

In case of medical emergency contact:*

Emergency Contact Information– Alternate Pickup/Release*

	Name	Phone Number	Relationship
Contact 1
Contact 2

Please list those people in addition to parents/guardians who are permitted to pick up your child:*

Cost Per Session: $500.00

Session 1: June 5th – 16thSession 2: June 19th – 30th
ATTENTION:

YOUR REGISTRATION IS NOT COMPLETE UNTIL YOU PAY ON THE LOWERY INSTITUTE WEBSITE.
*Multi session discounts are available. Parents have the option of having their children enroll in all four weeks of camp.

* Multi child discounts are available.

*Please call the Lowery Institute’s Main Office @404.524.8406 to inquire about special pricing. Ask to speak with Shawn Bender or Blake Osborne.

Camp Hours

Monday through Friday

Drop Off: 8:30 a.m. -9:00 a.m.

Duration 9:00 a.m. – 4:00 p.m.

After Hours: 4:00 p.m. – 5:30 p.m.

* A late fee of $1.00 will be charged for every minute after 5:30 your child remains onsite. This will be charged according to the Lowery Institutes clock. Late fees should be paid in full to the staff present immediately.
Parent/Guardian (1) Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*
Email:*
Occupation
Employer
Parent/Guardian (2) Full Name

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:
E-mail
Occupation
Employer
Camper shirt size:*
How did you hear about the Rising Change Agents Servant Leadership Camp?*
Other:
Signature: This signature will serve as your consent to the Terms of Agreement*

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Please sign below*
Signature*

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Lowery Institute’s Rising Change Agent Servant Leadership Camp Registration Form