Seeds of Joy - 2021 Summer Camp Registration

Student Summer Camp Registration Form

A nurturing, nursery school camp for ages 2-Pre-K
Please fill out, remit payment, scan and send in to
seedsofjoy@fpcambler.org or return in person.

If you have questions regarding camp, please see our website @ www.fpcambler.org/seeds-of-joy. Camp brochure and pricing is listed on the website. Church office phone is 215-646-3030.

Camp will run for 4 consecutive weeks in June and you may select all 4 weeks,
or select your choice of week(s).
Camp spots will be on a first come, first served basis.
Please register for best pricing option by MAY 13, 2021!
STUDENT INFORMATION
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PARENT 1 INFORMATION
Parent 1 Name

First Name Last Name
Parent 1 Email
example@example.com
Parent 1 Mobile Number
Parent 1 Home Phone
Parent 1 Work Number
Parent 1 Employer
PARENT 2 INFORMATION
Parent 2 Name

First Name Last Name
Parent 2 Email
example@example.com
Parent 2 Mobile Number
Parent 2 Home Phone
Parent 2 Work Number
Parent 2 Employer
PLEASE PROVIDE 2 EMERGENCY CONTACTS
Emergency Contact 1

First Name Last Name
Emergency Contact 1 Phone
Please enter a valid phone number.
Emergency Contact 1 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact 2

First Name Last Name
Emergency Contact 2 Phone
Please enter a valid phone number.
Emergency Contact 2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select the weeks your child will attend camp:

Week 1, June 7 - June 11 Week 2 June 14 - June 18 Week 3, June 21 - June 25 Week 4, June 28 - July 2
Please tell us about your camper - i.e., likes, dislikes, or any information that would be helpful to support your child during our camp time together.
CAMPER MEDICAL INFORMATION
Is the camper up to date on all immunizations?

YES NO
Please attach most recent immunization record here:

Cancel of
Please list any allergies to food, medication or environment:
Please list any surgeries, injuries or serious illness:
Please list any medicine taken regularly:
Is any medication required while at camp? If yes, please list below:
In an emergency, does your child require additional assistance (greater than other children of the same age) to evacuate the building?

Yes No
In the event of an emergency evacuation, are there medications or supplies that must be taken with your child?

Yes No
Is your child potty trained?

YES NO
Do you consent to topical product or lotion administered before high sun exposure to exposed area of skin?

YES NO
MEDICAL INSURANCE INFORMATION
Name of Policy Holder

First Name Last Name
Name of Insurance Company
Address of Insurance Company

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Policy Number
PAYMENT
Seeds of Joy Camp Menu:

Young Explorers: (2 to 3 years of age) (3 days - T, W, TH) $105/week

Investigators: (4 to 5 years of age) (5 days) $175/week.

Please remember to follow the payment link after submitting this application.

Please remember and note your total camp cost for completion of payment. You will need this later.

Please make all checks payable to:

FIRST PRESBYTERIAN CHURCH OF AMBLER.

Thank you!

My Choices

Young Explorer (2-3Yr Olds) 1 Camp Week Tuesday, Wednesday, Thursday, 9-12

$105	Quantity	Price
Cost per week (check payment)		$ 105.00
With 3% credit card fee		$ 108.15

Item subtotal: $ 0.00

Investigators (4 Yr Olds) 1 Camp Week Monday-Friday, 9-12

$175	Quantity	Price
Cost per week ( check payment)		$ 175.00
With 3% credit card fee		$ 180.25

Item subtotal: $ 0.00

Total

$ 0.00

Should be Empty:

Student Summer Camp Registration Form

STUDENT INFORMATION

PARENT 1 INFORMATION

PARENT 2 INFORMATION

PLEASE PROVIDE 2 EMERGENCY CONTACTS

CAMPER MEDICAL INFORMATION

MEDICAL INSURANCE INFORMATION

PAYMENT