Grass Roots Registration

Camper Name*

First NameLast Name

Camper Birthdate*

Date

Age*

Male or Female*

MaleFemale

Parent or Guardian Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent or Guardian Phone Number*

Please enter a valid phone number.

Parent or Guardian Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Do you have other children or relatives enrolled in the Grass Roots Program? If so, please input their full names.

Does your child have any allergies?*

YesNo

Does your child have any physical activity restrictions?*

YesNo

Does your child have any nut allergies?*

YesNo

Is your child susceptible to fainting?*

YesNo

Is your child susceptible to nose bleeds?*

YesNo

Is your child susceptible to motion sickness?*

YesNo

Is your child susceptible to convulsions?*

YesNo

If you answered yes, to any of the previous Health Questions, please explain here:

I hereby give permission for my child to participate in camp field trips and all camp activities (Unless specifically identified by parent or guardian). All campers are covered by accident insurance, however Montclair Grass Roots is only liable to the extent of it's insurance coverage for the period that the child is in camp.

I agree

Payment Options*

DEPOSIT for full 5 Week Camp Program 9 am - 3 pm . Cost is $750. A $100 deposit is required to register each child. Or you can make full payment by choosing the next option. You must register and pay for each child separately. Includes One Camper T-Shirt.Payment schedule for the balance:July 3rd - $350 payment due July 14th - $300 balance due

$100.00

FULL PAYMENT for 5 Week Camp Program 9 am - 3 pm. You must register and pay for each child separately. You must register and pay for each child separately. Includes One Camper T-Shirt.

$750.00

5 Weeks of Aftercare 3 pm - 5:30 pm. You must register and pay for each child separately.Extend your child's summer day camp experience until 5:30 pm

$200.00

Individual Week(s) of Summer CampChoose how many individual weeks you would like to enroll your child in summer camp.

$200.00 Quantity

Individual week(s) of Aftercare 3 pm - 5:30 pmExtend your child's summer camp experience until 5:30 pm

$50.00 Quantity

Grass Roots T-ShirtCamper T-Shirt . Tip: Buy extras so your child has a clean T-Shirt daily.

$10.00 QuantitySize

Total

$0.00

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