School Break Camp Registration Form'

2026-2027

School Break Camp Registration Form

Student's First Name

Student's Last Name

Grade Level

Home Address

City, State, Zip Code

Date of Birth

Month

Day

Year

Gender

Male

Female

County

Cobb

Paulding

Other

Interested Camps

Fall Break Camp — September 21–25, 2026

Winter Break Camp — February 15–19, 2027

Spring Break Camp — April 5–9, 2027

Are you interested in full-week enrollment or drop-in days?

Full Week Enrollment - $265

Drop-In Day(s) Only - $60 Per Day

Before & After Care:

We offer extended care for families who need additional flexibility.

Before Care: 7:00 - 8:00 AM ($10 per child per day)

After Care: 3:00 - 6:00 PM ($10 per child per hour)

Will your child need before or after care?

No, my child will not need before or after care.

Yes - Before Care Only

Yes - After Care Only

Yes - Both Before & After Care

If you selected before/after care, please indicate the days and times needed.

Parent First Name

Parent Last Name

Address (if different than student's address)

Email Address

Phone Number

Preferred method of communication

Phone

Email

Text

Please provide the name and phone number of an emergency contact (other than the parent/guardian listed):*

If you selected “Referral” above, please provide the name of the person who referred you to Excel At Math.

Medical & Safety Information: Does your child have any allergies, medical conditions, or take any medications we should be aware of? If yes, please provide details below.

Photo/Media Release: Do you give permission for your child to be photographed or recorded for use in promotional materials (i.e. website or social media)?

Yes, I give permission.

No, I do not give permission.

Camp Tuition & Discounts:

Weekly camp tuition is $275, and flexible drop-in attendance is available for $60 per day. Additional discounts may be available for sibling enrollment, school partnerships, and other special promotions.

For questions about camp pricing or to discuss the best option for your family, please contact us at 678-922-9516 or camp@excelatmath.org.

I acknowledge that I have read and agree to the camp policies listed above.

Signature: I attest that all information provided on this form is accurate and complete.

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Date

Month

Day

Year