CAMP BOUNCERS Enrollment Form
(Please complete one per child)
Child's Name (First and Last)
*
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 $180/wk)
Wk1: Jun 5 - Jun 9 ($190)
Wk2: June 12 - June 17 ($190)
Wk3: Jun 19 - Jun 23 ($190)
Wk4: Jun 26 - Jun 30 ($190)
Wk5: Jul 5 - Jul 7 ($190)
Wk6: Jul 10 - Jul 14 ($190)
Wk7: Jul 17 - Jul 21 ($190)
Wk8: Jul 24 - Jul 28 ($190)
Wk9: Jul 31 - Aug 4 ($190)
Wk10: Aug 7 - Aug 10 ($190)
Extended Hours Add On - 7am to 6pm ($25 /week)
School Break Camps (optional - only fill if you are selecting)
WinterBreak Camp Wk 1: Dec 18-22 ($190)
WinterBreak Camp Wk 2: Dec 27-29 ($135)
SpringBreak Camp: Mar 13-17 ($190)
Parent Guardian 1 Information
Parent/Guardian 1 Full Name
*
Relationship to Child
*
Address
*
Home Address
Street Address Line 2
City
State
Zip Code
Email Address
*
example@example.com
Cell Phone
*
Date of Birth
*
/
Month
/
Day
Year
Date
Parent 1 Gender
*
Female
Male
Employer
Work Phone
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
Date of Birth
/
Month
/
Day
Year
Date
Parent 2 Gender
Female
Male
Employer
Work Phone
Authorized Pickups Information
Authorized Pickup #1 Name
Authorized Pickup #1 Cell Phone
Authorized Pickup #2 Name
Authorized Pickup #2 Cell Phone
Authorized Pickup #3 Name
Authorized Pickup #3 Cell Phone
Emergency Contact Info
Name of Physician
*
Physician Address
Physician Phone
*
Hospital or Clinic (if preferred, optional)
Hospital or Clinic Address
Hospital or Clinic Phone Number
Please enter a valid phone number.
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
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Month
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Day
Year
Date
Signature
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