Summer Camp Registration Form
Please complete the form below to register your child for our summer programs.
Camper Information
Name
*
First Name
Last Name
Date of Birth
*
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Year
Age
*
Any allergies?
*
No known allergies
List allergies here
Any activity the camper should be restricted from?
*
Any physical, cognitive or other condition that would require special attention or medication while at camp?
*
Parent/Legal Guardian Information
Parent/Legal Guardian
*
First Name
Last Name
Relation
*
Email Address
*
example@example.com
Cell/Home Phone
*
Work Phone
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Parent/Legal Guardian (optional)
Parent /Legal Guardian 2
Relation 2
Email Address 2
example@example.com
Cell/Home Phone 2
Work Phone 2
Additional Emergency Contact
Emergency Contact Name (if parent or guardian is not available)
*
Emergency Contact Relation
*
Emergency Number
*
Emergency Number #2
Pick-up/Drop-off Authorization
Please list the names of ALL individuals who are authorized to pick-up your camper (including parents/guardians and emergency contacts entered above).
*
Camper Photo/Media Release
I agree that photos of my child can be taken and used in marketing materials.
*
Yes
No
Camp Selection & Payment
Register & Pay:
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July 8 - 12: Wild About Wetlands!
9am-3pm (postcare available between 3 -5:15pm @ $15/day). For ages 6-9.
$
250.00
July 15 - 19: Take Flight
9am-3pm (postcare available between 3 -5:15pm @ $15/day). For ages 6-12
$
250.00
July 22 - 26 : Junior Wildlife Rehabbers
9am-3pm (postcare available between 3 -5:15pm @ $15/day). For ages 10-12
$
250.00
July 29 - Aug 2: Reptiles and Amphibians
9am-3pm (postcare available between 3 -5:15pm @ $15/day). For ages 6-9
$
250.00
Aug 5 - 9: Wilderness 101
9am-3pm (postcare available between 3 -5:15pm @ $15/day). For ages 6-12
$
250.00
Aug 12 - 16: Forest Explorers
9am-3pm (postcare available between 3 -5:15pm @ $15/day). For ages 6-9.
$
250.00
Camp After-Care (Single Day)
3pm- 5:15pm. This can be added on to any amount of camps. Price is per day.
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
Camp-After Care (Full Week)
3pm - 5:15pm. This can be added on to any amount of camps. Price is for one week (5 days).
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Is your camper signed up for After-Care? If yes, please fill in what day(s) you have paid for. Please also include if you will be picking up your camper at 5:15pm or earlier. If no, please type N/A.
*
How did you hear about Chintimini Wildlife camps?
*
Returning Camper
Friend
Social Media
Website
Google Search
Chintimini e-news
Program at my child's school
Other
Terms & Conditions
Date & Time of Registration
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