Summer Camp Enrollment Form
Camper's Information
Camper's Name
First Name
Last Name
Age
Gender
Please Select
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
School/Grade Level
Parent/Guardian Information
The parents/guardian listed below will be the authorized person to pick-up the child after the camp. The parents/guardian listed below will also be the primary emergency contact person.
Name
First Name
Last Name
Relation
Phone Number
Name
First Name
Last Name
Relation
Phone Number
Medical Information
Does the child have any allergies? If yes, please list them below:
Does the child have any previous injuries? If yes, please explain them below:
Does the child have any current medical conditions? If yes, please list them below:
Does the child takes any medication? If yes, please list them below and explain its purpose:
Weeks Attending
June 24th-28th
July 1st-2nd
July 8th-12th
July 15th-19th
July 22nd-26th
July 29th-August 2nd
Payment Options
Please choose one of the following:
Procare (Automated weekly payments)
DHS Assistance
Authorization
I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached. I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary. I released the organizers, coaches, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment. I confirm that all information given in this form is true, complete, and accurate.
Parent/Guardian Signature
Print Form
Submit
Should be Empty: