Register for Summit (CANCELLED) Parent/Guardian Name * First Name Last Name Child Name First Name Last Name Parent Phone Number * (###) ### #### Parent Email * Age * 14 15 16 17 Does your child have any allergies to food, medication, bugs, etc.? * Yes No If yes to the previous question, please further explain. What are your child's interests and fears? Does your child have any dietary restrictions or take medication? * Emergency Contact Name * First Name Last Name Emergency Contact Phone Number * (###) ### #### How much are you comfortable paying? (See suggested amount based on income below) * Under $35,000: Free $35,000 to $50,000 : $100-200 $50,000 to $75,000 : $200-$350 $75,000 to $100,000 : $350-$650 $100,000 to $150,000 : $650-850 $150,000+ : $750-1,000 What are your hopes for your child in enrolling them in this program? Any additional details we should know? Thank you!
