CAMP BOUNCERS Enrollment Form
(Please complete one per child)
Child's Name (First and Last)
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Female
Male
School Name and Grade (current grade)
*
Summer Camp Selection (Camp Hours 8:30am to 4:30pm)
All Summer Weeks (Discounted Pricing of $185/wk)
Wk1: Jun 3 - Jun 7 ($195)
Wk2: June 10 - June 14 ($195)
Wk3: Jun 17 - Jun 21 ($195)
Wk4: Jun 24 - Jun 28 ($195)
Wk5: Jul 1 - Jul 3 ($195)
Wk6: Jul 8 - Jul 12 ($195)
Wk7: Jul 15 - Jul 19 ($195)
Wk8: Jul 22 - Jul 26 ($195)
Wk9: Jul 29 - Aug 2 ($195)
Wk10: Aug 5 - Aug 9 ($195)
Extended Hours Add On - 7am to 6pm ($25 /week)
School Break Camps (optional - only fill if you are selecting)
WinterBreak Camp Wk 1: Dec 23-24 ($135)
WinterBreak Camp Wk 2: Jan 30-3 ($195)
SpringBreak Camp: Mar 10-14 ($205)
Parent Guardian 1 Information
Parent/Guardian 1 Full Name
*
First Name
Last Name
Relationship to Child
*
Address
*
Home Address
Street Address Line 2
City
State
Zip Code
Email Address
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Date of Birth
*
/
Month
/
Day
Year
Date
Parent 1 Gender
*
Female
Male
Employer
Work Phone
Format: (000) 000-0000.
Parent Guardian 2 Information
Parent/Guardian 2 Full Name
Relationship to Child
Address
Home Address
Street Address Line 2
City
State
Zip Code
Email Address
example@example.com
Cell Phone
Format: (000) 000-0000.
Date of Birth
/
Month
/
Day
Year
Date
Parent 2 Gender
Female
Male
Employer
Work Phone
Format: (000) 000-0000.
Authorized Pickups Information
Authorized Pickup #1 Name
Authorized Pickup #1 Cell Phone
Format: (000) 000-0000.
Authorized Pickup #2 Name
Authorized Pickup #2 Cell Phone
Format: (000) 000-0000.
Authorized Pickup #3 Name
Authorized Pickup #3 Cell Phone
Format: (000) 000-0000.
Emergency Contact Info
Name of Physician
*
Physician Address
Physician Phone
*
Format: (000) 000-0000.
Hospital or Clinic (if preferred, optional)
Hospital or Clinic Address
Hospital or Clinic Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list problems or needs, including known allergies, existing illnesses, previous illnesses and injuries, any disabilities or behavior issues, any hospitalizations during the past twelve months, and any medication prescribed for long-term, continuous use, and any other information the staff should be aware of.
*
If none, please write“None”
Todays Date
-
Month
-
Day
Year
Date
Signature
Please verify that you are human
*
Submit
Should be Empty: