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!)

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.
Click Next to Select Date(s)

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

First NameLast Name
Parent/Guardian #1 mobile phone:
Please enter a valid phone number.Format: (000) 000-0000.
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?
Parent/Guardian #2 Name:

First NameLast Name
Parent/Guardian #2 mobile phone:
Please enter a valid phone number.Format: (000) 000-0000.
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?
Emergency Contact Name:

First NameLast Name
Emergency Contact mobile phone:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to the child:
Does the emergency contact have the authority from the parents/guardians to pick up the child from the program?

Click Next to Select Date(s)