Sample Summer Camp Registration Form

Little Lotus Summer Camp 2024 Registration Form

Summer camp begins July 08 until August 16, 2024. Pick up and drop off will be at 626 Flatbush Avenue (Maple Street School) each day. Tuition is 650.00 per week. Campers must register for a full week. We offer a 10% sibling discount. Tuition must be paid in full before your child attends. A non-refundable registration fee of $75.00, is due when you submit the registration form.
Camper Info
Camper 1
Name*

First NameLast Name
Birth Date*

MonthDayYear
Camper 2
Name

First NameLast Name
Birth Date

MonthDayYear
Home Phone*

Area CodePhone Number
Parent or Legal Guardian Information
Parent/Legal Guardian 1*
Relation*
Phone number*

Area CodePhone Number
Parents/ Legal Guardian 1 Email *
Parent /Legal Guardian 2 *
Relationship*
Phone Number*

Area CodePhone Number
Parent / Legal Guardian 2 Email *
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name and relationship to child(if parent or guardian is not available)*
Phone Number #1*

Area CodePhone Number
Emergency Contact Name and relationship to child(if parent or guardian is not available)*
Phone Number #2*

Area CodePhone Number
Health Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury.
Is camper free from infectious disease or conditions?*

YesNo
Are immunizations up to date?*

YesNo
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
Payment Information

$75 Registration Fee Due
If paying with PayPal you will be redirected to PayPal once you hit submit.
Camper Release
- Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks
Camper Release (List anyone, including parents, to whom your camper can be released)*
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18.

I understand that the above named camper will only be released to the names listed above, an update may be done at registration.

I certify that my child has my permission to attend camp and participate in all activites.
Signature*

Clear
My Products
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(Paypal or Credit Card)Registration Fee+Processing Fee$75.00

tuition for registered weeks$650.00

Quantity

Total $0.00
Electronic signature, please initial*
Please select week your child will attend*

July 08-July 12July 15- July 19July 22-July 26July 29- August02August 05-August 09August 12-August 16
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Little Lotus Summer Camp 2024 Registration Form

Camper Info

Camper 1

Camper 2

Parent or Legal Guardian Information

Health Information

Payment Information

Camper Release