Creative learning for children ages 3-13
July 3 - 28, 2017

Kaleidoscope 2013 Registration Form

Currently, only Fireworks classes are open for registration.

This form may be filled out online or printed & faxed to (978) 475-1422.
To download a printable form, click here.

Please be sure to check the CLOSED COURSE list before submitting your registration.

Note: Please do not use the enter key when filling out this form.

1st Child Current Grade Age as of 6/1/13 (Yrs) (Mos)
2nd Child Current Grade Age as of 6/1/13 (Yrs) (Mos)

Note: Current grade refers to child's grade in the 2012-2013 school year, not the grade he or she will be entering after the summer of 2013.

Parents' Names    
Address
City State Zip
Email Address
Please retype Email Address

Home Phone  # Cell Phone #
Emergency Phone # Other contact #
Please leave this field blank

Course Information

Please use schedule when listing codes.

First Child's Course(s)

Fireworks Code and Course Name
Please enter the code first to ensure the correct course placement.

Second Child's Course(s)

Fireworks Code and Course Name
Please enter the code first to ensure the correct course placement.

Quantity Description Amount
Each course at $275
Domino Physics ($90)
  Total
Please indicate method of payment  
Pay now with credit card via Paypal
Payment will be mailed as a check in 24 hours or less

Emergency Consent Form

Child's Doctor Doctor's Phone
Insurance Company Insurance Policy #
       
Child's Name Allergy
Child's Name Allergy


I, the undersigned parent or legal guardian of above named children will not hold Kaleidoscope, its agents, servants or employees responsible for any accidents incurred during participation in the Kaleidoscope program. If parents or doctor cannot be reached in case of emergency, consent is hereby given that the student receive medical treatment and/or surgical care as recommended by physician or hospital.

X
Parent Signature (required) Date

Your typed name is considered your signature



How did you hear about us?
 Website Word of Mouth  Brochure
 Advertisement Camp Fair   Other

Please click the submit button below to send your registration or print and then fax or mail this form.

If check is not mailed within 24 hours, registration cannot be confirmed.

Please make checks payable to KALEIDOSCOPE and mail directly to:
KALEIDOSCOPE
BOX 506
ANDOVER, MA 01810


Any questions?
Please call (978) 475-1422 days, nights and weekends and leave a message.

Print a copy of this form now for your records

Note: If you are using the PayPal option, please click submit first, then the PayPal link in the registration menu