Robotics & Code Day Camp — Sign Up

This single form registers your child for the October 30 day camp and covers all the required agreements. The full policy documents are linked next to each item — view all policies. By signing, you agree to them together, as allowed under Virginia's electronic-signature law. We'll follow up by email to confirm your spot and any fees.

1 · Child & parent

Child's first name *

Child's last name *

Child's grade *

Child's age

Parent / Guardian first name *

Parent / Guardian last name *

Email *

Phone *

Emergency contact — someone we can reach if we can't reach you.

Emergency contact — first name

Emergency contact — last name

Relationship to child

Emergency contact — phone

Emergency contact — email (optional)

2 · Camp day & options

Date: Friday, October 30, 2026 · Main camp: 9:00 am – 4:00 pm (included)
Tuition: $125 for the day (per child) · Where: STEM4U · 21690 Red Rum Dr #182, Ashburn, VA 20147

Need care outside the main day? Add it below — we'll confirm the add-on fees with you by email.

Early drop-off — 8:00 am (before the 9:00 am start) Late pickup — until 5:00 pm (after the 4:00 pm end)

3 · Agreements

Tap a policy name to read the full text. Checking the box means you've read and agree.

I have read and agree to STEM4U's Assumption of Risk, Release & Waiver, Code of Conduct, Child Safety Policy, and Pick-Up policy. * I authorize STEM4U staff to give basic first aid and, in an emergency, to call 911 and obtain emergency treatment for my child (per the Emergency Medical Authorization). * I understand the day-camp fee is $125 for the day and reserves my child's spot, and I agree to the Payment Policies (including any add-on fees I selected above). * I consent to electronic records and signatures — a typed name here is my legal signature, under Virginia UETA / the federal E-SIGN Act (details). *

4 · Emergency & medical info

Optional — just so our staff know what to watch for and can tell 911 responders. STEM4U staff do not administer medication; a student who carries emergency medication (e.g. an inhaler or EpiPen) self-administers it, and staff call 911 in an emergency.

Allergies or anything our staff should know

5 · Authorized pick-up

Adults (besides you) allowed to pick up your child. Staff may ask for photo ID.

Authorized adult 1 — name, relationship, phone

Authorized adult 2 — name, relationship, phone

May your child (13+) sign out and leave on their own?

6 · Photo & video

Your choice does not affect enrollment. (full release)

Yes — STEM4U may use my child's image to promote and document its programs. Limited — internal use only (private class recaps, program review). No public marketing or social media. No — please don't use my child's image in any STEM4U materials.

7 · Signature

By typing my name below I confirm I am the parent/legal guardian of the child named, that the information is accurate, and that I agree to all the STEM4U enrollment documents referenced above. This agreement is governed by the laws of the Commonwealth of Virginia.

Your first name (signature) *

Your last name (signature) *

I am the…

Date

✅

You're signed up!

We've recorded your Robotics & Code Day Camp registration and signed agreement for October 30.

💳 Last step — reserve your spot with Zelle

Send $125 per camper by Zelle to:

Stem4u

Put your camper's name in the Zelle memo so we can match your payment.

Your spot is confirmed once payment is received. We'll email you about any extended-care add-on fees (early drop-off / late pickup). Questions about payment? Email contact@stem4u.com.

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