Genius Camp Registration Please complete the form below and contact us by email or at 504-475-4522 to make arrangements to drop off your payment or mail a check or money order to the Learning Laboratory at 7100 St. Charles Avenue #203, New Orleans, LA 70118. Online Payment is also now available at http://mkt.com/learnlabnola. Add BOTH "Genius Camp Registration" & "Genius Camp" to your cart and pay with your credit or debit card. There is a 5% fee for this service. The total cost of Genius Camp is $500: $400+ $100 registration fee. You may reserve your child's spot with the (nonrefundable) registration fee. The full balance must be paid on or before May 15, 2017. Step 1 of 4 25% Payment Method*YOUR CHILD WILL BE UNABLE TO ATTEND GENIUS CAMP UNTIL PAYMENT IS COMPLETE.Online with debit/credit card (+5% processing fee added)Cash/check/money order in personHow did you find out about Genius Camp?*My child has already attended Lab programsEmailFacebookRadioTwitterWord of MouthCamp DetailsGenius Camp is a 4-week program for learners ages 8-14 years old. Please read and acknowledge the following details before completing registration. Learner's birthday must be between June 30, 2002 & August 4, 2009 for registration. Older students can inquire about volunteering opportunities and younger students can be enrolled in ABC Camp. The program runs from June 5-30, 2017, 8 a.m. to 3 p.m. daily on weekdays with a 30-minute "grace period" in the morning and afternoon. Parents are asked to drop off and pick up learners in a timely manner. Drop offs begin at 7:30 a.m. and pickups end at 3:30 p.m. Absences, late dropoffs and early pickups are strongly discouraged to ensure that each learner is present for the full program schedule. Pickups after 3:30 will be charged at a rate of $1 per minute. All learners will engage in daily physical activity, including, but not limited to morning walks and outdoor play at Audubon Park and weekly water days at Whitney M. Young Memorial Pool at Audubon Park. Learners will travel to Pensacola, FL by tour bus on June 28, 2017. We will leave New Orleans at 6 a.m. and return at 8 p.m. on this date. All camp participants are expected to attend the trip. Learners will bring a bag lunch, personal snacks and a refillable water bottle daily. Learners will be dismissed at 12 pm on Friday, June 30. There will be an evening event on this date (time TBA) for learners to share their work with parents and community members. Parent/Guardian InformationParent/Guardian Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/ Guardian Email Address Enter Email Confirm Email Primary Phone*Please provide a number (preferably mobile) that we can use to contact you if we need to talk to you about your child during the program.Alternate Phone*Please provide a secondary number that we can use to contact you if we need to talk to you about your child during the program.I would like to register ____ child(ren).*123 Student InformationStudent #1 Name* First Last Student #1 Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student #1 School*Student #1 Grade Level*Student #1 T-Shirt Size*SizeYouth Extra SmallYouth SmallYouth MediumYouth LargeYouth Extra LargeAdult Extra SmallAdult SmallAdult MediumAdult LargeAdult Extra LargePlease share any information we need to know about this student (#1)i.e food allergies, learning concerns, etc.Student #2 Name* First Last Student #2 Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student #2 School*Student #2 Grade Level*Student #2 T-Shirt Size*SizeYouth Extra SmallYouth SmallYouth MediumYouth LargeYouth Extra LargeAdult Extra SmallAdult SmallAdult MediumAdult LargeAdult Extra LargePlease share any information we need to know about this student (#2)i.e food allergies, learning concerns, etc.Student #3 Name* First Last Student #3 Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student #3 School*Student #3 Grade Level*Student #3 T-Shirt Size*SizeYouth Extra SmallYouth SmallYouth MediumYouth LargeYouth Extra LargeAdult Extra SmallAdult SmallAdult MediumAdult LargeAdult Extra LargePlease share any information we need to know about this student (#3)i.e food allergies, learning concerns, etc. Emergency InformationEmergency Contact*Please provide the name of someone we can contact if the parent/guardian listed above is unavailable in the case of an emergency. First Last Relationship to student(s)*Emergency Contact Phone Number*Emergency Contact Alternate Phone Number Informed Consent and AcknowledgementIn consideration of my child’s participation in programs provided by the The Learning Laboratory New Orleans, Inc., I indemnify and hold The Learning Laboratory New Orleans, Inc. and its affiliates, employees and agents harmless from and against any and all liability for negligence or medical expenses resulting from my child’s participation in such programs or other activities. I further release The Learning Laboratory New Orleans, Inc. and its affiliates, employees and agents from any and all negligence or other claims resulting from my child’s participation. I further understand that The Learning Laboratory New Orleans, Inc. does not provide medical insurance coverage for my child and that any medical expenses incurred will be paid by either my own medical insurance or myself. I hereby grant permission for my child to participate in all activities. I give permission for my child’s photo and/or likeness to be retained and used by The Learning Laboratory New Orleans, Inc. without any remuneration or compensation. BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.Electronic Signature*Type your name First Last I will attend a mandatory parent information meeting at the following date/time:*7:30-8:00 a.m. on Monday, June 5, 20173:00-3:30 p.m. on Monday, June 5, 2017NameThis field is for validation purposes and should be left unchanged.