Parent/Guardian/Placement Provider Name
*
First Name
Last Name
Email (consent/waiver forms and camp communication will be sent to this email)
*
example@example.com
Child Name
*
First Name
Last Name
Child's Date of Birth
*
Week
*
Please Select
Week 1 June 26 - 29
Week 2 July 10 - 13
*Please note that a maximum of 10 campers per week will be allowed
Will the child be utilizing transportation from the Riverblock building?
*
Yes
No
Submit
Should be Empty: