Please provide the following information. You will receive an e-mail confirmation of the receipt of this form.

^{* Required Fields}
Camp Location*      Class Code*
Start Date*:     End Date*:      
Start Time*     End Time*

Child's Name*:     Birthday*:     
Child's School*: 
Please list any health concerns: 
After camp my child will*:  Be Picked-up by     Contact Number for this person

Parent Name*     E-mail *  
Daytime  Phone*  Evening Phone*  Cell Phone
Street Address* 
City*  State*  Zip* 

Camp Program Cost*  : per student
    *Some camp fees may vary.  Some Park & Recreation Districts have a small additional non-resident charge.  Please see the form sent home or our website for specific details of a particular camp.  Actual amount charged to your credit card will be the amount indicated on these sources.  If you have any questions call 303-403-0432 prior to submitting this form.

Credit Card Type* (Visa/MC Only):
Credit Card Number⁽¹⁾:
Name on Card*
Address (If different then above):
Expiration Date:

By providing this information you authorize Mad Science of Denver to charge your credit card in the amount indicated above.  You give permission for your child to attend the Mad Science class and acknowledge that you have read and understand the cancellation and refund policies for the Mad Science of Denver Enrichment program.  

(1) Please note: This e-mail method of registration will require you to provide credit card information.  This information will be e-mailed to Mad Science of Denver's registration desk.  This method does not use secure connection technology.  While Mad Science of Denver will take precautions to safeguard this information we can not be responsible for unauthorized access of this data by non-Mad Science of Denver employees.  If you are uncomfortable with this registration method, please write "Call In" in the credit card number field and call our offices at 303-403-0432 Monday Friday, 9am 4:30pm to provide your credit card number.