Irvine Math and Music Academy (IMMA) Summer Camp
Registration Form (3 pages)
Session A
Session B
June 27 – July 8
(no class July 4th)
July 11 – July 22
July 25 – August 5
K-1
A-K1__
8:30 – 11:30
B-K1__
8:30 – 11:30
C-K1__
8:30 – 11:30
2-3
A-23___
8:30 – 11:30
B-23__
8:30 – 11:30
C-23__
8:30 – 11:30
School
Grade
2011-2012
Session C
Registration and Payment Information:
 Regular registration:______________ by 05/14/2011
 Early registration ($30 off):________ by 04/14/2011
 Siblings discount: ____________ 10% (same family)
 Multiple sessions discount: ____10% (same camper)
 Refunds: ____________________100% by 05/14/11;
75% by 05/30/11; 50% by 06/13/11
 Mail-in registration:
Fill in, print and mail out registration form along with the check
payable to IMMA (Irvine Math and Music Academy) to:
I. Khurgel, c/o Irvine Math and Music Academy
16 Wintersweet Way, Irvine CA, 92612
4-6
A-46__
12:30 – 3:30
B-46__
12:30 – 3:30
C-46__
12:30 – 3:30
7-8
A-78__
12:30 – 3:30
B-78__
12:30 – 3:30
C-78__
12:30 – 3:30
Tuition
$558
$620
$620
Enrollment for each session is limited to ensure the
effectiveness of the program.
Spaces are reserved in order payments are received.
Early registration is recommended.
Tuition total: $
One-time Registration Fees (non-refundable; per student)
$35
One-time Material Fees (per student, for all sessions)
$40
Payment Total
$
Page 1
Irvine Math and Music Academy Summer Camp  1530 Concordia West, Concordia University Student Union, Room 203  Irvine, CA 92603
www.mathandmusicacademy.com  (949)509-7766 (Music)  (949)436-5108 (Math)  info@mathandmusicacademy.com
Student Information (required):
First name: ____________________Middle initial: ___ Last name: _____________________
Nickname/Preferred name: ____________
Date of birth: _____________ Gender: M_____ F_____
School/Grade (Fall 2011): _________________________________
Extracurricular activities:_________________________________________________________
_____________________________________________________________________________
Favorite snack:________________________________
Allergies/special needs:_______________________________________________
Math:
Course completed in the 2010-2011 school year: ________________
Gifted program enrolment: Y___ N___
Area(s) of strength: ________________________________________________________________
Problem solving experience (grades 4 – 8): None_____ Beginner________ Intermediate_________ Advanced________
Music:
School music classes completed in the 2010-2011 school year: ________________
Music taken outside of school: Yes___ No___
If Yes, how many years?____ What instrument?________________________
Notes reading experience: None_____ Beginner________ Intermediate_________ Advanced________
Page 2
Irvine Math and Music Academy Summer Camp  1530 Concordia West, Concordia University Student Union, Room 203  Irvine, CA 92603
www.mathandmusicacademy.com  (949)509-7766 (Music)  (949)436-5108 (Math)  info@mathandmusicacademy.com
Parent/Guardian Information:
Parent/Guardian 1 (required):
First name: ______________________Middle initial: ___ Last name: ________________
e-mail address: ______________________________
Home address: _________________________________________________________
Home phone: ___________________Cell phone: _____________________ Work phone: _____________________
Parent/Guardian 2 (required):
First name: ______________________Middle initial: ___ Last name: ________________
e-mail address: ______________________________________________
Home address: _________________________________________________________
Home phone: ____________________Cell phone: _______________________Work phone:__________________________
Other Emergency Contact:
First name: ______________________Middle initial: ___ Last name: ________________
Relationship:__________________________
Home address:_________________________________________________________
Home phone: ____________________Cell phone: ________________________Work phone: _____________________
____________________________________________________________________________________________________
I hereby acknowledge that the information I provide is true and will be kept private.
I further acknowledge that I have read and agree with terms of the service
Submit__________ Reset__________
Page 3
Irvine Math and Music Academy Summer Camp  1530 Concordia West, Concordia University Student Union, Room 203  Irvine, CA 92603
www.mathandmusicacademy.com  (949)509-7766 (Music)  (949)436-5108 (Math)  info@mathandmusicacademy.com