Summer Camp Registration

Emergency Contact/ Parental Consent Form
Name of Child*
Age*
Sex*
Race*
Birthdate*

MonthDayYear
Date
Grade Entering*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Siblings in Lancaster Rec Child Care*
N/A if no siblings
Primary Name/ Legal Guardian*
Complete Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #*
Please enter a valid phone number. If no number then please enter 000-000-0000
Cell Phone #*
Please enter a valid phone number. If no number then please enter 000-000-0000
Email*

Confirmation Emailexample@example.com
Employer Name*
Business Phone #*
Please enter a valid phone number. If no number then please enter 000-000-0000
Complete Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to add an additional parent or legal guardian?*
Secondary Name/ Legal Guardian*
Please enter First and Last Name. N/A is Default
Email*
example@example.com, N/A is the default
Home Phone #*
###-###-####. N/A is the default
Cell Phone #*
###-###-####, If no number then please enter 000-000-0000. N/A is the Default
Address*
Please enter address. N/A is the default
City*
Please enter City
State*
Example PA.
Zip Code*
N/A is the default
Employer Name*
Please enter employer Name. N/A is the default
Business Phone #*
###-###-####. N/A is the default
Address*
Please enter Address. N/A is the default
City*
Please enter City
State*
Example: PA.
Zip Code*
N/A HIDE

Childs's Medical Information
Name of Child's Physician/Medical Care Provider*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Special Disabilities*
Please list Disabilities*
Allergies (including medication reaction)*
Please list allergies*
Medical or Dietary Information Necessary in an Emergency Situation*
Please list any Medical or Dietary Information*
Medication/ Special Conditions*
Please list any Medications/Special Conditions*
Additional Information on Special Needs of Child*
Type None if not applicable
Hospital Choice*
Health Insurance Coverage for Child or Medical Assistance Benefits*
Name of Health Insurance
Policy Number*

Electronic Funds Transfer Payment Agreement
I, First Name* Last Name* authorize my bank to make payment by the method indication below, and post it to my account.
How will you pay for Camp?*
Credit Card Type*
Example: Visa, MasterCard, American Express
Name on Card*
Credit Card Number*
Expiration Date*
Example: 07/24
Security Code (on back)*
Bank Name*
Routing Number*
Account Number*
Customer Signature*

Clear
Date

MonthDayYear
Date

Document Uploads
Child Health Assessment*

**Currently enrolled families can upload a note saying "Already on file at LRC"**
Cancelof
Child Immunization Record*

**Currently enrolled families can upload a note saying "Already on file at LRC"**
Cancelof
Childs' IEP

Cancelof
Custody Agreement

Cancelof
Should be Empty:

Para español oprima la bandera en la esquina derecha