Pelican Therapy Partners
Summer Camp
CHILD INFORMATION:
Child Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
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Day
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Year
Which Days/sessions would your child like to attend?
*
Please Inform Us of Anything Else You Would Like Us to Know About Your Child:
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
MEDICAL INFORMATION
Physician Name
First Name
Last Name
Phone Number
Medical Concerns
Pelican Therapy camps
If paying by check please make check payable to Pelican Therapy Partners and BRING check to 463155 SR 200 UNIT 12, Yulee FL 32097 or mail to 75259 Plumbago Trace YULEE, FL 32097. $50 dollars required to reserve a spot in each session for a full session and $40 for a partial session. Or full weekly rates 175 or 215. Checks must be received by Dec 21.
Paying By Check
Online Payment options ( Fees Applied) (select quantity for camp numbers your child will attend)
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Summer Camp Full Session
Down payment for winter enrichment camps! Please make sure to designate which day(s) of camp they would like to attend. If attending more than one session please choose payment method for each number of sessions you wish to attend i.e for 3 days change quantity to 3. $3.00 processing fee if paying by card or PayPal.
$
43.00
Quantity
1
2
3
4
5
6
7
8
9
Item subtotal:
$
0.00
Summer Camp Half Session
Down payment for winter enrichment camps! Please make sure to designate which day(s) of camp they would like to attend. If attending more than one session please choose payment method for each number of sessions you wish to attend i.e for 3 days change quantity to 3. $3.00 processing fee if paying by card or PayPal.
$
28.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Camp Sign up Themes
Schools out- May 31
Sports-June 7
Circus- June 14
Space- June 21
Ocean- June 28
Safari- July 12
Arts and Crafts-July 19
Christmas- July 26
Beach- August 2
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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