Rock the Summer AGAIN! - 2021 Summer Camp Registration

Student Name *

First

Last

Age *

Grade Level *

Parent/Guardian *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Summer Camp - $750 Material Fee + $2,250 Camp Fee *

$3,000 Total
$400 Classroom Peer Only (LIMITED SPOTS)
$100 Non-Refundable Registration Fee

*Non-refundable Registration Fee Due Upon Registration

Payment Source: *

Private Pay (Out of Pocket)
Autism Scholarship
Franklin County Pilot Program

Location: Choose One *

Central (Worthington)
North East (Johnstown)
South (Canal Winchester)

Student T-Shirt Size *

Total Paid

$0.00

*Non- Refundable Registration Fee MUST Be Paid with Registration ($100.00)

By Initialing this Form I understand that This is a Binding Non-Refundable Fee. *

Behavior Clause / Teacher Shortage - Please Initial after reading *

*** TLS BEHAVIOR CLAUSE: IN ORDER TO ENSURE A SAFE AND EFFECTIVE LEARNING ENVIRONMENT, THE LEARNING SPECTRUM ASKS THAT STUDENT'S BEHAVIOR BE MANAGEABLE INDEPENDENTLY IN A SMALL GROUP SETTING*** ***Due to the national teacher shortage, enrollment for summer programming cannot be guaranteed until May 15, 2022. Registration Fee will be refunded if necessary.