Camp Registration Form

Camp Registration Form

To participate in this virtual summer camp, parents must complete the form below and submit a registration fee of $75 (Early Registration Fee is Valid until May 12, 2023-- $95 regular registration fee). Weekly camp fees are $85. Please be advised that all school-age campers (i.e. 5 yrs. to 14 years) will receive an activity kit with registration. The STEAM Youth Summer Camp is June 5 - July 28, 2023.
Camper's Name: *

First Name Last Name
Birth Date: *

Month Day Year
Child 2

First Name Last Name
Birth Date:

Month Day Year
Child 3

First Name Last Name
Birth Date:

Month Day Year
Home Phone Number: *

Area Code Phone Number
Email Address:
Primary Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Medical Information

In order to provide the best possible handling of certain situations, please complete the following medical information:
Does camp participant have an allergy to insect stings?
If yes to the above question, please identify? blanks .
Have an allergy to penicillin or particular serums?
If yes to the above question, please indicate which? blanks .
Have diabetes?
Have epilepsy?
Have other allergies or disabilities that EBLLC should be made aware of?
If yes to the above question, please describe? blanks .
Is there any other health condition that may effect your child's participation in any part of camp activities? (mental/physician limitation or condition?
If yes to the above question, please describe/explain? blanks .
What is the name of your family physician? blanks field.
Other relatives and/or neighbors who will assume temporary care of your child if you cannot be reached.
1. blanks (Name & Phone)
2. Type a label (Name & Phone)
In case of an accident or serious illness and that Easton Banks Learning & Life Center is not able to reach me, I hereby authorize program staff to call the physician indicated on the registration form and follow his/her instructions, as well as contacting the "temporary care" person(s) listed above. I also understand that in the event of an emergency, the Easton Banks Learning & Life Center will make its first call to 911.
School Information
School Name
School District *
Year in School: *
T-Shirt Size *

Parent Information
Parent/Guardian's Name: *

First Name Last Name
Contact Phone Number: *

Area Code Phone Number
Mobile Number:

Area Code Phone Number
E-mail Address: *
How did you hear about this Camp?: *
Do you or someone in your household receive any type of public assistance?
Does your child (ren) have any food allergies?

Yes No
What are your expectations for the STEAM Summer Youth Camp?
In 300 words or less, please describe what you expect for your child to gain from attending this camp. (optional)

0/300
Authorization for Pick-Up
In the event that I am unable to pick up my child(ren) at the scheduled time on the days that camp participants meet in person, I grant permission to the following persons. I further understand that staff of Easton Banks Learning & Life Center will charge $5.00 per minute. I also understand that this payment is due at the time of pick-up and should be made payable to the staff member who had to wait for the camp participant's parent/guardian.
1st Authorize Person

First Name Last Name
2nd Authorized Peron

First Name Last Name
3rd Authorized Person

First Name Last Name
For my child to have the ultimate experience attending the STEAM Summer Youth Camp, I acknowledge that I will be obligated to pay Easton Banks Learning & Life Center, Inc. a weekly fee of $85. I, further understand that fees are due the Friday before the next week of camp activities and no later than the Monday of the week of scheduled activities. If I am unable to fulfill this obligation I will inform camp administration immediately by calling 470-778-7189 or emailing info.bankslearning@yahoo.com.

I acknowledge and adhere to the payment policy and confirm by my signature below.
Signature

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Camp Registration
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Camp Registration Fee $ 75.00
This payment covers the initial registration fee and provides for camper's camp t-shirt and activity kit.

Quantity

Total $ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Camp Registration Form

Medical Information

School Information

Parent Information

What are your expectations for the STEAM Summer Youth Camp?

Authorization for Pick-Up