Imagination Stage: Our Classes

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Summer Registration Form

Please complete the following form to register online and pay by credit card. You may also download a summer registration form (PDF) and mail or fax it to Imagination Stage.

Camp tuition must be paid and registration form must be completed before a student may attend camp. Please allow 6 business days from the time you submit the registration form until it is fully processed, your credit card is charged and you receive your email confirmation. (An email confirmation is only sent when a valid email address is provided). In May, you will receive an email from us with additional details and any necessary forms to be completed. Please let us know if you do NOT receive EITHER the conformation email or the May email with camp details.

Please review our Summer Registration Policies.

Questions: 301-961-6060 or TTY: 301-718-8813

Please fill in the form. Fields with an asterisk (*) are required.

1. PARENT/GUARDIAN INFORMATION

Parent/Guardian Information

Please enter your name and address as they are listed for your debit card, credit card, or bank account.

A valid email address is required for confirmation of registration and to receive important class information from the student’s teacher.

Salutation:

First Name:

Last Name:

Address:

City:

State:

Zip/Postal Code:

Email:

Evening Phone:

Daytime Phone:

Emergency Phone:

Employer:

Parent/Guardian #2

Salutation:

First Name:

Last Name:

Employer:

Daytime Phone:

2. HOW DID YOU FIRST HEAR ABOUT US?

Information

Please select the option that best describes how you heard about Imagination Stage classes.

I am a current or former student /camper
Received brochure in the mail
Attended a Performance at Imagination Stage
Word of Mouth
Other Website
E-newsletter
Children's Guide to Arts Activities (AHCMC backpack flyer)
Magazine Ad, which magazine?
Newspaper Ad/Article:
Attended a summer camp fair, please specify which one:
Other - Please specify:

3. STUDENT INFORMATION

Student Information

Please enter the name and date of birth of the student; along with the Grade they are in and the full name of the school they are attending.

Please list any notes or special needs the student may have.

Student Gender:

Student First Name:

Student Last Name:

Student Birth Date (e.g. 6/10/2000) :

Grade in Fall 2009:

Full Name of School Attending:

Medication:

Please list any medications that your child is taking. Imagination Stage respects the privacy of the information you choose to share with us, but in the unlikely event of a medical emergency it will be necessary to share this information with qualified medical and health professionals.

Name of Physician:

Physician Number:

The Access Department at Imagination Stage: Our Access Department works to provide a wide range of support services to students who have important health concerns or disabilities. It is critical that we have the proper information on your child so that we may best meet her needs and safety requirements. Please take a moment to provide the following information even if your child has attended programs with Imagination Stage in the past. A member of our Access staff will follow up with all new registrants to share an overview of the Access philosophy and programs and the procedures Imagination Stage follows for determining class placement and necessary accommodations for students with disabilities.

Please check all that apply:

	ADD		Development Delays
	ADHD		Diabetes
	Allergies		Down's Syndrome
	Asthma		Dyslexia
	Autism		Epilepsy
	Asperger's Syndrome		Language Delays
	PDD/NOS		Sensory Integration Disorder
	Cerebral Palsy		Tourette's Syndrome
	Deaf/Hard of Hearing		Vision Impairment / Blind / Low Vision
	Other

Are there any additional concerns or information you would like to share with us about your child?

How can we best meet the needs of your child? List any behavioral strategies that work best for him/her.

4. CHOOSE YOUR CLASSES

Class Information

If you need help finding the appropriate class or if you have questions, contact your mentor. If you have problems with this form, please contact the registration manager.

You may use this form to register for up to three classes per student. Please click the drop down arrow to select your class.

Class 1 ID#
Day
Time
Start
Weeks
Holidays

Tuition

Class 2 ID#

Day
Time
Start
Weeks
Holidays
Tuition

Class 3 ID#

Day
Time
Start
Weeks
Holidays
Tuition

5. ADD ANOTHER STUDENT

+ Add A Second Student

Hide Second Student

Student Gender:

Student First Name:

Student Last Name:

Student Birth Date (e.g. 6/10/1990) :

Grade in Fall 2009:

Full Name of School Attending:

In order to best serve each student, please indicate if your student has any physical, cognitive, emotional, learning or other special needs. We encourage parents to also fill out the Need to Know Form and mail or drop it off at Imagination Stage as soon as possible (please read our Registration Policies for a complete description of our inclusion policies for Summer Camps).

You may also leave other notes here for the registration manager or for your student’s teacher.

Notes/Special Needs: Must be 250 characters or less.

You may use this form to register for up to three classes per student. Please click the drop down arrow to select your class.

Class 1 Student 2 ID#

Day
Time
Start
Weeks
Holidays
Tuition

Class 2 Student 2 ID#

Day
Time
Start
Weeks
Holidays
Tuition

Class 3 Student 2 ID#

Day
Time
Start
Weeks
Holidays
Tuition

+ Add A Third Student

Hide Third Student

Student Gender:

Student First Name:

Student Last Name:

Student Birth Date (e.g. 6/10/1990) :

Grade in Fall 2008:

Full Name of School Attending:

You may also leave other notes here for the registration manager or for your student’s teacher.

Notes/Special Needs: Must be 250 characters or less.

You may use this form to register for up to three classes per student. Please click the drop down arrow to select your class.

Class 1 Student 3