2022 SCHOOL BREAK CAMP Enrollment Form
Girls Day Camp: Located at 2974 Ask Kay Dr Smyrna
Camper's Information
Camper's Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
21-22 School/Grade Level
Camper's Photo (Optional)
*
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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
-
Area Code
Phone Number
Picture upload
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of
Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
Browse Files
Cancel
of
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:
How did you hear about us?
Facebook
Instagram
Family/Friend
Street Sign
Payment Details
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.
My Products
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Daily Drop In
$
50.00
Quantity
0
1
2
3
4
5
Fall Break Camp
$
215.00
FULL DAY
Fall Break Camp
$
155.00
HALF DAY
Enter coupon
Apply
Total
$
0.00
Credit Card
Parent/Guardian Signature
Clear
Submit
Print Form
Should be Empty: