Summer Camp 2022 Enrollment Form

ADDITIONAL INFORMATION
Physician Name

First Name Last Name
Physician Phone Number

Area Code Phone Number
Dentist Name

First Name Last Name
Dentist Phone Number

Area Code Phone Number
Relevant Medical Concerns or General Information for Day Camp (ie: asthma, diabetes, compromised immune system, etc.)
Does your child take medication regularly? *

Yes No
If your child requires medication regularly, what is this medication and when is this medication administered?
Does this camp participant have allergies to bee or wasp stings? Please give details in the space provided. *
Does this camp participant have any food allergies, sensitivities? Please give details in the space provided. *
Does this camp participant have any behavioral or medical conditions that we should know about? Please give details in the space provided. *

Permissions Section
I give permission for my child, to wear sunscreen. I understand that I will provide sunscreen with my child’s name clearly printed on the bottle. I may apply sunscreen on my child before they come to the Center, and will inform the teacher(s)if this is the case. The teachers have my permission to reapply sunscreen as needed throughout the day. *

Please allow my child to apply his/her own sunscreen, as needed during camp. Please apply sunscreen on my child as needed.
We take photos throughout the week to make photo albums on the last day of each week. Some of these photos are so great we want to post them on social media. Do we have your permission to publicly post a photo of your child?

Yes No
Please list the full name and the cell phone number for each of the people who have permission to pick up your child from camp. If you would like to add or remove from the list, you will have the chance to do so on the first day of camp when you submit the camper emergency card. *
If you indicated that you would like early-morning drop off, please give us more details here.
Is there anything else that you would like to share with us?

PAYMENT INFORMATION
NAME OF INDIVIDUAL RESPONSIBLE FOR PAYMENT

First Name Last Name
RELATIONSHIP OF RESPONSIBLE PERSON TO CAMPER
HOW WOULD YOU LIKE TO PAY FOR CAMP? *

I would like to mail in a check or money order (please pay for the $25 deposit to hold your spot and deduct the $25 from your check. Mail your check to: 15 Mountain View Court Santa Cruz, CA 95062 and put your child's name and the camp week on the memo of your check. I can pay now with a credit card
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Deposit for Camp. $ 25.00
This is NON REFUNDABLE. We will contact you regarding billing.

Total $ 0.00
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Summer Camp Registration 2022