2022 Summer Camp Registration Form
Camper's Information
Camper #1 Name
*
Camper # 1 Date of Birth
-
Month
-
Day
Year
Date
Camper #1 Gender
*
Female
Male
Camper #2 Name
Camper # 2 Date of Birth
-
Month
-
Day
Year
Date
Camper #2 Gender
Female
Male
Camper #3 Name
Camper # 3 Date of Birth
-
Month
-
Day
Year
Date
Camper #3 Gender
Female
Male
Camper #4 Name
Camper # 4 Date of Birth
-
Month
-
Day
Year
Date
Camper #4 Gender
Female
Male
Primary Language Spoken at Home
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Home Phone
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Name
*
Or enter N/A if not applicable
Parent's Work/School Phone
Parent's Work/School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached while your child is at camp?
*
Cell Phone
Work Phone
Home Phone
Parents' Information
Parent/Guardian 2
Parent/Guardian 2
First Name
Last Name
Relationship to Child
E-mail
Cell Phone
Home Phone
Home Address Same as Parent/Guardian 1?
Yes
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Name
Or enter N/A if not applicable
Parent's Work/School Phone
Parent's Work/School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Work Phone
Home Phone
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Emergency Contacts/Authorized Pickup
Emergency Contact #1
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
*
Relationship to Child
*
Emergency Contacts/Authorized Pickup
Emergency Contact #2
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Secondary Phone Number
*
Relationship to Child
*
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Authorized Pickup - Name and Number
Medical / Health Information
Name of Physician or Clinic/Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Does your camper(s) have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please list and explain any allergies per child
*
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
*
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?
*
Yes
No
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
0/150
If yes, does this medication, food supplement, or medical food need to be administered at the day camp?
*
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
*
0/150
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Camp Selection Payment and Policy Statements
Select Your Summer Camp Choices
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( X )
Equestrian Camp
$
375.00
Session I - June 27th - July 1st 8:00am-4:00pm
Number of Campers
1
2
3
4
5
6
7
8
9
10
Urban Adventure Camp
$
275.00
Session II - July 11th - July 15th 8:30am-3:30pm
Number of Campers
1
2
3
4
5
6
7
8
9
10
Entreprenuer Camp
$
275.00
Session III - July 25th - July 29th 8:30am-3:30pm
Number of Campers
1
2
3
4
5
6
7
8
9
10
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
I have read and agree to the Technology and Internet Policy
*
Yes
No
I have read and agree to the Media Release Terms.
*
Yes
No
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
Date Picker Icon
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