Camp_Reg

Check All That Apply
*

June 10 - June 14
June 17 - June 21
June 24 - June 28
July 8 - July 12
July 15 - July 19
July 22 - July 26
July 29 - August 2
August 5 - August 9
August 12 - August 16
August 19 - August 23
Select a Time
*

From 9 am to 2 pm
From 7:30 am to 6 pm ( Extended Care )
Student Name -1
*
Birth date: (MM/DD/YY)
*
Gender
*
T - Shirt
Student Name -2
Birth date: (MM/DD/YY)
Gender
T - Shirt
Student Name -3
Birth date: (MM/DD/YY)
Gender
T-Shirt
Parent/Guardian’s Name
*
Address
*
- Street Address
- Address Line 2
- City
- State / Province / Region
- Postal / Zip Code
- Country
Phone Number
*
Email Address
*
THE FOLLOWING IS REQUIRED TO BE ATTACHED TO THIS FORM (Parent to check box indicating task is complete)
*

I have read, understood, and agreed to the Liability Waiver form. The above information is true to the best of my knowledge.
EMERGENCY CONTACT NAME
*
EMERGENCY CONTACT Phone Number
*
Does the Participant take Medication

YES
NO
If YES, name the medication, dosage, times given and doctor’s name and contact number in the space provided below.
Full Name
The following people are authorized to pick up your child from our facility. All identified persons MUST present a photo ID before picking up your child. Please identify all persons authorized for pick up
Date
*

EMERGENCY CONTACT

EMERGENCY CONTACT

PAYMENT