Summer Camp Registration Form 2022

Summer Camp Registration Form 2022
Camper Information
Child #1 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade entering in Fall 2022 *
Child's T-shirt size (Each camp receives 1 free camp t-shirt) *

Youth XS Youth S Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL
Would you like to register another child? *

Yes No
Child #2 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade Entering Fall 2022 *
Child's T-shirt size (Each camp receives 1 free camp t-shirt) *

Youth XS Youth S Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL
Would you like to register another child? *

Yes No
Child #3 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade Entering Fall 2022 *
Would you like to register another child? *

Yes No
Child's T-shirt size (Each camp receives 1 free camp t-shirt) *

Youth XS Youth S Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL
Child #4 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade Entering Fall 2022 *
Child's T-shirt size (Each camp receives 1 free camp t-shirt) *

Youth XS Youth S Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian #1 *

First Name Last Name
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Best Phone to Use During the Day *

Cell Home Work
Parent/Guardian Email (This is the email that will be used for primary communication.) *
example@example.com
Does your child have a Parent/Guardian #2? *

Yes No
Parent/Guardian #2 Name *

First Name Last Name
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Best Phone to Use During the Day *

Cell Home Work
Email
example@example.com
Emergency/Medical Information
In case of an emergency, parents/guardians will be contacted first. Please list the names & numbers of up to two additional contacts who will be called if parents/guardians cannot be reached.
Emergency Contact #1 *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Child/Children *
Emergency Contact #2

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Child/Children
Please list the people who are authorized to pick up your child/children from camp (changes can be made to your list later) *
Summer camp staff need to be aware of any medical issues (such as allergies or diabetes) as well as any physical, social or congnitive challenges that your child/children might have. All information will be kept confidential.
Would you like to explain any medical issues or challenges for your child/children? *

Yes No
Please do so here.
Child/ren's Physician
Phone Number

Area Code Phone Number
Choose your Camps
Click the camps for which you are registering: *

Jr. Roleplayers: The New Republic WAITING LIST, ages 12 - 17, (July 11 - 22, 2022) History in Play: Growing Up Victorian WAITING LIST, ages 9-11 (July 11 - 15, 2022) History Alive Session I WAITING LIST, ages 6-8 (July 18 - 22, 2022) Survivor SBM WAITING LIST, ages 10 - 12 (July 25 - 29, 2022) Jr. Roleplayers: Industrial Age WAITING LIST, ages 12 - 17 (August 1 - 12, 2022) Victorian DIY, ages 6 - 8 (August 1 - 5, 2022) Victorian Ventures WAITING LIST, ages 9 - 11 (August 8 - 12, 2022) History Alive Session II WAITING, ages 6 - 8 (August 15 - 19, 2022) History in Play: Growing Up Between the Wars WAITING LIST, ages 9 -11, (Aug 15 - 19)
If needed, please clarify which children are doing which camps.
In order to be prepared to costume your child, please list your child(ren)'s height and pants size that you believe they will be at the time of camp. If you have multiple children please list names next to each answer (ex. John: 5'0', size 12-14) *
Release and Consent
Please list the full name(s) for each child attending camp. *
I/We authorize Strawbery Banke Museum staff to arrange for emergency care for my/our minor child/children at a local hospital, as the staff deems necessary. I/We authorize hospital personnel to provide emergency medical treatment for my/our child/children.

I/We wish that my/our child/children participate in camp program(s) which is/are organized by Strawbery Banke Museum during the summer of 2022. I assume all the risks of injury and loss arising or resulting from my/our child's/chldren's participation, hereby releasing and holding harmless the Museum, its employees or agents from liability for any such injury or loss.

Unless otherwise informed, I/We allow our child to appear in photographs taken for use in Strawbery Banke Museum publications, publicity and social media. I also agree to allow photographs from camp to be available on a password protected site, to which only fellow camp families have access.
Please type your name(s) into the box below. By doing so, you are certifying that you are the parent and/or legal guardian of the minor participant(s) listed above, and you understand and are in agreement with the waivers indicated above. *
Membership Status
Are you a Member of Strawbery Banke Museum (family level or higher)? *

Yes No I don't know
Is the child's parent/guardian on active duty in the military?

Yes No
Don't forget to scroll to or choose the FAMILY MEMBER section during payment to get your member discount! Children of parents on active duty in the military receive the member price too.
Summer Camp Payment

A deposit is required to secure your space in camp. You can opt to pay in full now using the form below or skip payment here and receive an invoice via email that will allow partial payment. If you want to skip payment, scroll to the bottom and hit the submit button.
If you are registering more than one child or one child for more than one camp, use the code MCD2022 to receive 10% off.

Click the down arrow next to the category that applies to your membership status.

Non-Members

Victorian DIY (August 1 - 5, 2022) ages 6 - 8 $ 325.00

Quantity

Strawbery Banke Family Members

Victorian DIY (August 1 - 5, 2022) ages 6 - 8 $ 275.00

Quantity

Enter coupon

Total $ 0.00

Should be Empty:

Summer Camp Registration Form 2022

Camper Information

Parent/Guardian Information

Emergency/Medical Information

Choose your Camps

Release and Consent

Membership Status

Summer Camp Payment