Summer Camp Registration Form

Student Registration form

Summer Day Camp
Child's Name

First NameLast Name
Nickname
Date of Birth

MonthDayYear
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select a camp week:

June 14th-18thJuly 12th-16thAugust 2nd-6th
Please select a session:

AM (8:45-12:00)PM (1:00-4:15)Full day
Academic information
School your child is currently attending
Entering grade 2021/2022
Does your child have any learning disability? if so, please explain.
Do you think your child is at the right academic level for his/her grade? Please explain.
Parent/Guardian Information
Parent/Guardian's Name

First NameLast Name
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Parent/Guardian's Name 2

First NameLast Name
Relation 2
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.

Emergency Contact Information
Emergency Contact

First NameLast Name
Relationship
Emergency Contact Phone
Please enter a valid phone number.
Emergency Contact Alternative Phone
Please enter a valid phone number.
Medical Information
Is your child's immunization record up to date?

YesNo
Health Insurance Company
Health Insurance Policy Number
Physician's Name
Any activities child should be restricted from?
Any physical, mental or other condition that would required special attention or medication while at camp?
List any allergies

Payment Information

Each session is $250/week. Full day session (am + pm) is $400/week.
A $50 non refundable deposit is required at time of registration. You may choose to make your payment electronically with Zelle or Paypal, or send a check. If you prefer to send a check, we will send you an email providing address. For electronic payments, please use the email - apablaza.fernanda@gmail.com - to make payment.
Method of Payment

Electronic (Zelle, Paypal)Check
By hitting submit and putting your signature, you agree that you are the parent or legal guardian of the above named child, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. The camp carries secondary insurance. I understand that the above named child 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
Should be Empty:

Student Registration form