Eugene Creative Care Summer Camp Interest Form

Eugene Creative Care

2023 Summer Camp Interest Form
Student Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade (for school year 2023-24)
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Please choose an option

5 days/week - $950/month4 days/week - $775/month3 or less days/week - $575/month
Private Pay or ERDC/DHS

Private PayERDC/State Pay - Already QualifiedERDC/State Pay - Application Pending Approval
If you are currently enrolled with an ECC after school program, your 2022-23 registration will carry through until Fall when another registration will be due. New families to our Summer Camp will be required to pay a $50 registration fee and fill out a registration form, which you will receive by email. Spots are limited, so please return your forms and pay your registration fee as soon as possible to ensure your child's spot is secure.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Eugene Creative Care