After School Program Registration

After School Program Registration

Winter '22 Holiday Play Camp Registration

by Play Studio
Please fill out a separate form for each child.
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear

My child will be attending:

WEEK Winter Holiday Play Camp$350.00

Monday December 19th-Friday December 23rd9am-4pm

MONDAY Winter Holiday Play Camp $75.00

Monday December 19th 9am-4pm

TUESDAY Winter Holiday Play Camp$75.00

Tuesday December 20th 9am-4pm

WEDNESDAY Winter Holiday Play Camp$75.00

Wednesday December 21st 9am-4pm

THURSDAY Winter Holiday Play Camp$75.00

Thursday December 22nd 9am-4pm

FRIDAY Winter Holiday Play Camp$75.00

Friday December 23rd 9am-4pm

Total $0.00

Credit Card

Parent/Guardian #1 Name*

First NameLast Name
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Email*
example@example.com
Mobile Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Parent/Guardian #2

First NameLast Name
Email
example@example.com
Mobile Number

Area CodePhone Number
Home Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
If yes, please list allergy type, reaction, and treatment.
YesNo
Physician Name*

First NameLast Name
Physician Phone Number*

Area CodePhone Number
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact person (other than listed parent)*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Child
Additional person authorized to pick-up my child from after school care:
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to child
yesno
Is there anything else you'd like for us to know about your child?
Please verify that you are human*
Signature

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