Virtual Summer Camps - Code Academy

Student Name

First*

Middle

Last*

Address

Street*

City*

Postal Code*

Date Of Birth*

Gender*

Male
Female

Virtual Summer Camp*

Tech Code (9:30AM - 12:30PM) ($200 + HST)
Tech-Art (9:30AM - 12:30PM) ($200 + HST)

Tech Code Dates

Tech-Art Dates

School Name*

Grade*

Parent information

Father's Name*

Cell Number

Home Phone Number

Work Phone Number

Email

Mother's Name*

Cell Number

Home Phone Number

Work Phone Number

Email

Other Siblings

Yes
No

Name of Brother/Sister

Date of Birth

Grade

Media Permission*

I Agree to have my child participate in publicity and promotional opportunities.
I Do Not Wish my child participate in publicity and promotional opportunities.

Publicity and Promotional Opportunities: Your child may be photographed or videotaped while participating in regular learning activities at Code Academy Learning Center. This provides an opportunity for your child to represent the center and/or receive recognition for achievement. Examples may include news releases, program announcements, brochures, and social media, including Facebook, Twitter, and YouTube.
Please check the appropriate box and sign and date this form to indicate whether you consent to having your children participate in publicity opportunities.

Parent Signature*

Date*

Credit Card*

Visa
Master Card

Name on the Card*

Expiry Date (MMYY)*

Credit Card Number*

CVV*

Purpose of Debit: Debit Camp fees payable to Code Academy Ltd.

Additional Information:

Signature of Authorized Account Holder(s)*

Date*