Children's Summer History Days at Peachfield Registration Form

Children's Summer History Days at Peachfield Registration Form

Saturday, June 22, July 27, and August 24, 2024 from 9:00am-3:00pm Peachfield 180 Burrs Road, Westampton, NJ 08060 **All children must be between the ages of 6-12 prior to date of program.
My Child's Name*

First NameLast Name
My Child's Birth Date*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please describe any allergies for your child:
Will your child need to self-administer any medications while at camp? Are there any medical needs we should be aware of? Please describe: (Example: Asthma, sun sensitivity, diabetes, etc.)
I'd like to register another child: (Siblings get 10% off!)

Yes (Enter second child's information on next page)No (Skip to Program Date Selection)

My Child's Name

First NameLast Name
My Child's Birth Date
Please describe any allergies:
Will your child need to self-administer any medications while at camp? Are there any medical needs we should be aware of? Please describe: (Example: Asthma, sun sensitivity, diabetes, etc.)
I have a third child I'd like to register, please email me to make arrangements.

YESNO
Click Next to Select Date(s)

My child(ren) will register for the following Summer History Days at Peachfield*

Saturday, August 24, 2024 from 9am-3pm
Select Next to Enter Parent/Guardian/Emergency Contact Info.

Parent/Guardian/Emergency Contact Information
Parent/Guardian #1 Name:*

First NameLast Name
Parent/Guardian #1 mobile phone:*
Please enter a valid phone number.
Parent/Guardian #1 Email Address: **If selecting online payment, this is the email address we will send an e-invoice to.*
example@example.com
Will Parent/Guardian #1 act as an emergency contact for the child and have the authority to pick up the child from the program?*

YESNO
Parent/Guardian #2 Name:

First NameLast Name
Parent/Guardian #2 mobile phone:
Please enter a valid phone number.
Parent/Guardian #2 Email Address:
example@example.com
Will Parent/Guardian #2 act as an emergency contact for the child and have the authority to pick up the child from the program?

YESNO
Emergency Contact Name:*

First NameLast Name
Emergency Contact mobile phone:*
Please enter a valid phone number.
Relationship to the child:*
Does the emergency contact have the authority from the parents/guardians to pick up the child from the program?*

YESNO

Click Next to Select Date(s)