Boston Roundtable S.T.E.A.M. Camp at Pomfret School - Registration Form

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S.T.E.A.M. Camp at
Pomfret School
Registration

Welcome to our S.T.E.A.M. Camp at Pomfret School registration page. Please complete all information about your student in Part One, then proceed to reserve their session spot in Part Two. If you have any questions, you may submit them at our contact page. Be sure to check off "Educational Camps" under "What does your message concern?"

Part One: Student Information Form

I: Student Information

* Indicates required field

1. First Name: *

2. Last Name: *

3. Age *

5. Date of Birth: *

6. Grade: *

4. Gender: *

If "Other," Please Specify: *

7. Preferred Nickname *

II: Relationship to Pomfret School

8. Current Pomfret School student? *

Yes No

10. Is either parent an alumni of Pomfret School? *

Yes No

12. If you answered "Yes" to question 10, did they have a different name when you attended? If so, what was it? *

9. If you answered "No" to Question 8, what school does the student currently attend? *

11. If you answered "Yes" to question 10, what year did they graduate? *

13. Are you a faculty or staff member at Pomfret? *

Yes No

II: Location

Note: This registration form is for US domestic students only - international students wishing to enroll must contact Dylan@BostonRoundtable.org.

14. Address: *

Line 1

Line 2

City

State

Zip Code

Country

15. Family Email: *

16. Home Phone: *

III: Family Information

17. Guardian 1 Name: *

19. Guardian 1 Cell Phone: *

18. Guardian 1 Relationship to Student: *

20. Guardian 1 Work Phone: *

21. Guardian 1 Email: *

22. Student Emergency Contact? *

Note: Upon confirmation of enrollment, the person designated as "Guardian 1" will be the primary contact for the student and will receive email updates and important information from Boston Roundtable leading up to the camp.

23. Guardian 2 Name: *

25. Guardian 2 Cell Phone: *

24. Guardian 2 Relationship to Student: *

26. Guardian 2 Work Phone: *

27. Guardian 2 Email: *

28. Student Emergency Contact? *

IV: Emergency Information

Note: If you have already indicated one or more guardians as the emergency contact, you may leave that information blank here.

29. Emergency Contact Name: *

31. Emergency Contact Email: *

30. Emergency Contact Relationship to Student: *

32. Emergency Contact Cell Phone: *

33. Please indicate any allergies your child has (i.e. medications, food, bee stings, etc): *

V: COVID-19 Risk Assessment

34. In the unlikely event of a medical emergency requiring medical attention, do you grant permission for the camp nurse or physician to attend to your child? *

Yes No

35. Has your student been diagnosed with COVID-19 (coronavirus)? *

Yes No

36. Within the past 14 days, has your student experienced any of the following? *

Fever Cough Shortness of Breath None of the above

37. Within the past six months, has your student travelled to any of the following places (check all that apply)? *

China Iran Italy Japan Singapore South Korea My child has not travelled to any of these places in the past six months

Please note that we will continue to monitor news alerts on the school systems of enrolled students.

38. Has your student's school at any point been closed due to COVID-19? *

School closed due to a student, teacher, or other community member diagnosed with COVID-19 School closed due to concerns over COVID-19, but no student, teacher, or other community member diagnosed School not closed

VI: Photo Waiver

VII: Certification of Accuracy

Certification: *

I hereby grant permission to Boston Roundtable to use photographs and/or video of my child taken during the duration of their camp session at Pomfret School in publications, news releases, online, and in other communications related to the educational mission of Boston Roundtable.

PLEASE NOTE: The photo waiver only requests permission to use your child's image. Boston Roundtable will never reprint a student participant's name without expressly written consent of their parent or legal guardian.

Certification: *

By checking this box, you certify that all information in this form is true and correct to the best of your knowledge.

VIII: Referral

IX: Additional Comments

How did you hear about us? (Pease check all that apply) *

Flyer at my child's school Flyer in a public location (i.e. coffee shop, library, local business) Facebook Ad Google Ad PTA Visit Ad in Pomfret Chamber of Commerce Word of mouth Camp Fair Visit Other

If you were referred by a specific person, please indicate their name here: *

Does this person have a student enrolled in the camp? If so, please indicate their name here: *

Additional Comments or Questions (optional): *

Submit

Part Two: Selecting a Session

Once you have submitted the registration form, you may reserve the student's spot by going to our "Choose Your Session" page and paying the enrollment fee. Please note that registration is not complete until you complete this page.

Our online payment system accepts all major credit cards. If you would prefer to use a different payment method, please contact us directly at Contact@Boston-Roundtable.com.

Choose a Session

Get in Touch

Telephone

781-281-0435

Email

Contact@BostonRoundtable.org

Address

100 Tower Office Park, Suite L
Woburn, MA 01801

S.T.E.A.M. Camp atPomfret School​​Registration

Part One: Student Information Form

I: Student Information

II: Relationship to Pomfret School

II: Location

III: Family Information

IV: Emergency Information

V: COVID-19 Risk Assessment

VI: Photo Waiver

VII: Certification of Accuracy

VIII: Referral

IX: Additional Comments

Part Two: Selecting a Session

Get in Touch

Telephone

Email

Address

S.T.E.A.M. Camp at
Pomfret School
Registration