Kid's College Registration Form

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NOTE: You are not officially registered until all fees are paid.

The college is required to have the student's correct SSN per IRS Code, Section 6109.

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION:

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Student SSN:
Date of Birth:
School:
Grade:

GENDER:

Male
Female

ETHNIC ORIGIN: (Required by the Federal Gov't)

Are you Hispanic? YesNo RACE: Choose one or more (for Non-Hispanics) WhiteAsian
Black/African AmericanAmerican Indian/Alaska Native
Native Hawaiian/Pacific Islander

Mother's Name:
	Daytime Phone:
	Evening Phone:
	Email Address:
Father's Name:
	Daytime Phone:
	Evening Phone:
	Email Address:

Choose week(s) and track:
Elementary School Students (Entering grades 2, 3, 4 and 5)
Track One (For students entering grades 2 and 3) Track Two (For students entering grades 4 and 5)
Middle School Students (Entering grades 6,7 and 8)
June 20-24
Shining Stars on Stage Scientific Discoveries In the News All Around Campus

July 11-15
Shining Stars on Stage Scientific Discoveries In the News All Around Campus

Fee:	$120 per week per student
Schedule:	Mon-Thurs 8:30am-4:00pm
	Fri 8:30am-12:00pm

PAYMENT INFORMATION:

Refund deadline is 7 days before camp start date

Payment is made by: CheckCredit Card

If making payment by Check, please print out a copy of this form and mail the form and your payment no later than June 26th to:
GCSC, Business Affairs
5230 West U.S. Hwy 98
Panama City, FL 32401

Name on Card:
Card Type:	VisaMasterCardAmerican Express
Card Number	- - -	Exp. Date	Amount	$