Clone of Form

QSMPT Summer Camp

1st and 2nd Grade
Camper's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Grade (as of last school year)*

1st2nd
Shirt Size*

Primary Contact*

First NameLast Name
Primary Contact Phone Number*
Please enter a valid phone number.
Primary Contact Email Address*
example@example.com
Secondary Contact*

First NameLast Name
Secondary Contact Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Camper Medical Information
Doctor Name*
Doctor Phone Number*
Please enter a valid phone number.
Does the camper have allergies?*

YesNo
What are the camper's allergies?
Does the camper have asthma?*

YesNo
Does he/she use an inhaler?

YesNo
❖ Important Note
Please note peanut butter sandwiches are restricted and not allowed as snacks or lunch

I understand that this payment is not tax-deductible*

I understand

Group 1:*

Week 1 (July 5- 7)

$150.00

Pick from below	Quantity	Price
Regular Hours (8 A.M- 4 P.M)		$150.00
Early Drop (7 A.M- 4 P.M)		$175.00
Late Pick up (8 A.M- 5 P.M)		$175.00
Early & Late Combined (7 A.M- 5 P.M)		$185.00

Item subtotal:$0.00

Week 2 (July 10- 14)

$200.00

Pick from below	Quantity	Price
Regular Hours (8 A.M- 4 P.M)		$200.00
Early Drop (7 A.M- 4 P.M)		$225.00
Late Pick up (8 A.M- 5 P.M)		$225.00
Early & Late Combined (7 A.M- 5 P.M)		$235.00

Item subtotal:$0.00

Week 3 (July 17- 21)

$200.00

Pick from below	Quantity	Price
Regular Hours (8 A.M- 4 P.M)		$200.00
Early Drop (7 A.M- 4 P.M)		$225.00
Late Pick up (8 A.M- 5 P.M)		$225.00
Early & Late Combined (7 A.M- 5 P.M)		$235.00

Item subtotal:$0.00

Week 4 (July 24- 28)

$200.00

Pick from below	Quantity	Price
Regular Hours (8 A.M- 4 P.M)		$200.00
Early Drop (7 A.M- 4 P.M)		$225.00
Late Pick up (8 A.M- 5 P.M)		$225.00
Early & Late Combined (7 A.M- 5 P.M)		$235.00

Item subtotal:$0.00

Week 5 (July 31- August 4)

$200.00

Pick from below	Quantity	Price
Regular Hours (8 A.M- 4 P.M)		$200.00
Early Drop (7 A.M- 4 P.M)		$225.00
Late Pick up (8 A.M- 5 P.M)		$225.00
Early & Late Combined (7 A.M- 5 P.M)		$235.00

Item subtotal:$0.00

Week 6 (August 7- 11)

$200.00

Pick from below	Quantity	Price
Regular Hours (8 A.M- 4 P.M)		$200.00
Early Drop (7 A.M- 4 P.M)		$225.00
Late Pick up (8 A.M- 5 P.M)		$225.00
Early & Late Combined (7 A.M- 5 P.M)		$235.00

Item subtotal:$0.00

Total

$0.00

By signing this form I Parent name* do certify that my child is physically & emotionally fit to participate in allcamp activities & field trips,
I clearly do fully understand & comprehend the risk of my child might be in by participating in the summer camp activities.
I do waive all the any liabilities now & in the future of the camp sponsors Priests, deacon, board, volunteers of any wrong doing or negligence that might happen & have any effect on my child physically or emotionally now or in the future.
Should be Empty: