Sample Summer Camp Registration Form

Summer Camp Registration

June 13th- July 21st , 2023
Camper Name
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Camper's Information
Address*
City*
State*
Zip*
Home Phone*

Area CodePhone Number
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Camper's age
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Email Confirmation
Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)
Other Information
How did you hear about Artist With A Purpose Summer Camp?
Have Siblings? (If yes, subtract $25 from camper fee)*

YesNo
Health Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration please inform the director of the changes.
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
LIST ANY ALLERGIES (ex: bees, peanuts, dairy)*
Any dietary needs that we should know about? Students are required to bring their own lunches. Snacks will be provided. Please be sure to add any allergies in box above.*
Payment Information

Registration fee is payment for the first week of camp. $115 per week. $25 off each additional sibling a week.
If paying with PayPal you will be redirected to PayPal once you hit submit. You can either pay with a credit card or PayPal. (Do not select goods and services when submitting payment to avoid an extra fee.) The weekly payment is due every Monday. The fee is a WEEKLY PAYMENT ONLY. NO DAILY RATE. If you have any questions feel free to contact Artist with a Purpose at 352-705-8741.
My Products
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Registration Fee$35.00

Quantity

Summer Art Camp Fee (Half day)$280.00
June 10-14, 2024 9 a.m.-12 p.m.

Summer Art Camp Fee (Full day) $315.00
June 10-14, 2024 9 a.m.-4 p.m.

Spring Art Camp Fee (Half day) $250.00
March 12-15, 2024 9 a.m.-4 p.m.

Spring Art Camp Fee (Full day) $350.00
March 12-15, 2024 9 a.m.-4 p.m.

Spring & Summer Art Camp Fee (Full day) $665.00
Spring and Summer camp Full Day 9 a.m. -4 p.m.

Spring & Summer Camp Fee (Half day) $630.00
Spring and Summer Camp Half-Day 9 a.m -12. p.m.

Total $0.00
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)*
- Be certain to enter your email address correctly on the registration form to receive confirmation via email.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above-named camper, and are over the age of 18. In case of a medical emergency or general medical care, I give consent for medical treatment for the above named camper by authorized personnel. The camp carries secondary insurance. I understand that the above-named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activities. I authorize Artist with a Purpose to use my camper's picture, testimony, and video in any promotional material(web, print, or media).
Signature*

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Electronic signature, please initial*

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Summer Camp Registration

Camper Name

Camper's Information

Parent or Legal Guardian Information

Email Confirmation

Other Information

Health Information

Payment Information

Camper Release