Grass Roots Registration

Camper Name*

First NameLast Name

Camper Birthdate*

Date

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.Format: (000) 000-0000.

Parent or Guardian Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

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

YesNo

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

I agree

My Products

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 5th - $350 payment due July 18th - $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 Camp

Choose 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 pm

Extend your child's summer camp experience until 5:30 pm

$50.00 Quantity

Grass Roots T-Shirt

Camper T-Shirt . Tip: Buy extras so your child has a clean T-Shirt daily.

$10.00 QuantitySize

Other Payment Method

$ Free Quantity

Total

$0.00

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Montclair Grass Roots