2022 Eco Kids Summer Camp Registration Form

Eco Kids Summer Camp 2022
CHILD/CHILDREN INFORMATION:

(Registering 3 or more children at a time may be eligible for a discount!)
1) Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
2) Child's Name

First Name Last Name
Date of Birth

Month Day Year
Date
3) Child's Name

First Name Last Name
Date of Birth

Month Day Year
Date
4) Child's Name

First Name Last Name
Date of Birth

Month Day Year
Date
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Medical Information
Physician Name *
Physician Number *
Medical Concerns, Required treatment, name of child (if more than one). Should ambulance be called?
Is your child presently being treated for an injury, illness or taking any form of medication? If yes, please explain.
Does your child require a special diet? If yes, please explain.
Emergency Contact
Name *
Contact Number *
Email
Relation to Child(ren) *
Not including the parent/guardian listed above, please list any additional persons permitted to pick up your child/children:
Registration and Payment
Will you require FULL DAY care for your child/children (8:30am- 4:30 pm)? *

YES NO
Each week has a different theme. Please indicate the week(s) you are registering for: *

Week 4 - August 2-5* Healthy & Eco Kids Week 5 - August 8-12 Be a Planeteer!
- $150 per child/ per week.
- 10% coupon only applies when paying for 3 or more children at a time.
- Full payment is required in order to submit registration

Payment

Summer Camp Payment $ 150.00 CAD

Please enter the number of weeks you have selected above.

Child(ren)/Week
Item subtotal: $ 0.00 CAD

Enter coupon

Total $ 0.00 CAD

Credit Card

Should be Empty:

Eco Kids Summer Camp 2022

CHILD/CHILDREN INFORMATION:

PARENT/GUARDIAN INFORMATION:

Medical Information

Emergency Contact

Registration and Payment

Credit Card