Sample Summer Camp Registration Form

Little Lotus Summer Camp 2022 Registration Form

Summer camp begins July 05 until August 31,2022. Pick up and drop off will be at Lincoln Road and Ocean Avenue each day. Tuition is 500.00 per week. Campers must register for a week. We offer a 10% sibling discount. Tuition must be paid in full before your child attends .. Registration fee of $75.00, is due when you submit registration form.
Camper Info
Camper 1
Name *

First Name Last Name
Birth Date *

Month Day Year
Camper 2
Name

First Name Last Name
Birth Date

Month Day Year
Home Phone *

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

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

Area Code Phone Number
Parents Email *
example@example.com
Emergency Contact Name and relationship to child(if parent or guardian is not avaliable) *
Phone Number #1 *

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

Area Code Phone 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? *

Yes No
Are immunizations up to date? *

Yes No
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
Electronic signature, please initial *
Please select week your child will attend *

July 05-July 08 July 11- July 15 July 18-July 22 July 25- July29 August 01-August 05 August08-August 12 August 15-August 19 August 22- August 26 August 29 - August 31
My Products
Categories: All

All
prev next ( X )
(Paypal or Credit Card)Registration Fee+Processing Fee $ 75.00

tuition for registered weeks $ 500.00

Quantity

Total $ 0.00
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Little Lotus Summer Camp 2022 Registration Form

Camper Info

Camper 1

Camper 2

Parent or Legal Guardian Information

Health Information

Payment Information

Camper Release