2021 Summer Camp Session Sign-Up Form

2021 Summer Camp Session Sign-Up Form

16110 Dream Oaks Place, Bradenton, FL 34212 | Phone: 941-746-5659 | Fax: 941-745-1409
YOUR CHILD WILL NOT BE REGISTERED UNTIL A $50 NON-REFUNDABLE FEE IS PAID

An annual up to date physical MUST be turned in 2 weeks prior to camp.
CAMPER INFORMATION
How did you hear about us?
Returning Camper New Camper
Camper Name *

First Name Last Name
Sex *
Height *
Weight *
Ethnicity
Date of Birth *

Month Day Year
Date
Age *
Disability/Primary Diagnosis *
Address *

Street Address

Street Address Line 2

City State

Zip Code
County *
Parent/Guardian Name *

First Name Last Name
Email *
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Recent illness, injury, or behavioral change

BILLING AND PAYMENT

Check the desired payment options below. Pay by credit card below or make check payable to Foundation for Dreams
Check the desired payment option below: *

Payment option 1- FULL PAY I will send a check or call (941)746-5659 to make full payment of $650/$400 per camp session. A $50.00 portion is non-refundable. Payment option 2- PARTIAL PAY I will send a check or call (941)746-5659 to make a $50.00 non-refundable payment to be applied to the total cost of each camp session. The balance remaining will be paid in full prior to the start of camp. Payment option 3- SCHOLARSHIP/FINANCIAL ASSISTANCE NEEDED I have a low income or financial hardship and have submitted the attached Scholarship Application Form. I will send a check or call (941) 746-5659to make payment of the non-refundable $50.00 for each camp session. I have submitted the most recent proof of income for my HOUSEHOLD. Payment option 4- OUTSIDE FUNDING I will be receiving funding through an outside source to pay. I understand I am responsible for payment for any agency funding which is not obtained. (You MUST provide contact information.)
If Payment Option 4 is selected, please fill out the following information:
Agency
Agency Contact Person
Agency Phone
Contact Email
example@example.com
Agency Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PLEASE READ AND SIGN: I acknowledge that acceptance into the desired camp session(s) is NOT guaranteed and is contingent upon space availability.
Signature *

Clear
Date *

Month Day Year
Should be Empty:

2021 Summer Camp Session Sign-Up Form

CAMPER INFORMATION

2021 SUMMER CAMP SESSIONS

BILLING AND PAYMENT