Summit Academy Summer Camp Registration Form 2023
July 3-21, 2022
Camper's Name:
Grade/Class in September:
Current School:
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent's Name:
First Name
Last Name
Parent's email address:
Alternate email address:
example@example.com
Emergency contact (other than parent)
Parent's Number
-
Area Code
Phone Number
Please register my child for:
Week 1 (July 3-7)
Week 2 (July 10-14)
Week 3 (July 17-21)
Does your child have any restrictions, medical needs, allergies, etc.?
Is your child medically cleared for sports?
Yes
No
Unsure
Ha your child been diagnosed with a learning difference or behavioral challenges?
Yes
No
If you answered "yes' above, please explain below:
Payment Options
Online Payment
Office Payment
Student Activity Account Deduction
Please add to my June tuition invoice (current/incoming Summit students only)
Other
Phone number of emergency contact:
Name of parent/guardian completing form
First Name
Last Name
Submit
Should be Empty: