IRVINE MATH AND MUSIC ACADEMY (IMMA) SUMMER CAMP-2011
Mail-In Registration Form
PLEASE SELECT SESSION(S)/APPLICABLE DISCOUNTS, AND ENTER TOTAL PAYMENT AMOUNT TO BE MAILED OUT
School
Grade
2011-2012
K-1
2-3
4-6
7-8
Session A
June 27 – July 8
(no class July 4th)
A-K1
□
8:30 – 11:30
A-23
□
8:30 – 11:30
A-46
□
12:30 – 3:30
A-78
□
12:30 – 3:30
Session B
July 11 – July 22
B-K1
□
8:30 – 11:30
B-23
□
8:30 – 11:30
B-46
□
12:30 – 3:30
B-78
□
12:30 – 3:30
Session C
July 25 – August 5
C-K1
□
8:30 – 11:30
C-23
□
8:30 – 11:30
C-46
□
12:30 – 3:30
C-78
□
12:30 – 3:30
Registration and Payment Information: (mark boxes)

Regular registration: _______________ by 05/14/2011
 Early registration ($30 off): _________ by 04/14/2011
□
□

Siblings discount (same family):_____ $50 off
□
 Multi-session disc. (same camper):___ $50 off
□

Registration:
Print and fill out registration form, mail along with the check payable to the Irvine Math and Music Academy to:
I. Khurgel, c/o Irvine Math and Music Academy
16 Wintersweet Way, Irvine CA, 92612
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.
Refund Policy:__________________ 100% before 05/14/2011
_________________ 75% before 05/30/2011
_________________ 50% before 06/13/2011
Tuition $558 $620 $620 Tuition total: $____
One-time registration fee (per student, non-refundable)
Materials fee (per student, per session)
$35
$40
Payment Amount $____
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

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 1 (required):
First name: ______________________Middle initial: ___ Last name: ________________ Relationship:__________________________ e-mail address: ______________________________
Home address: _________________________________________________________
Home phone: ___________________Cell phone: _____________________ Work phone: _____________________
Parent/Guardian 2 (optional):
First name: ______________________Middle initial: ___ Last name: ________________ Relationship:__________________________ e-mail address: ______________________________________________
Home address: _________________________________________________________
Home phone: ____________________Cell phone: _______________________Work phone:__________________________
Emergency Contact (required):
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
Signature:_____________________________________________ Date:___________________________
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