Adventure Camp Registration 2024
9:00AM-12:00PM each day of camp
Camper's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Grade entering
*
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Parent/Guardian Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you give permission to allow the registrant to go in water?
*
Yes
No
Would the registrant like to be grouped with any specific people?
If no, please leave empty. If yes, please write down the names that the registrant would like to be in the same group as. NOTE: Groups will consist of either all girls or all boys in the same age range.
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Medical Information
Does the registrant have any allergies? Food, medication, drugs, etc?
If no, please leave textbox empty. If yes, please explain.
Is the registrant presently taking any medications or on any special diet or exercise restrictions? Please include all over-the-counter medications such as Tylenol, etc
If no, please leave textbox empty. If yes, please explain.
Does registrant have any known physical disability or illness which might interefere with their participation in strenuous activity?
If no, please leave textbox empty. If yes, please explain.
Does the registrant have any emotional/social disabilities that would be helpful for us to be aware of?
If no, please leave textbox empty. If yes, please explain.
Does the registrant have any history of concussions?
If no, please leave box empty. If yes, please explain.
Other information that the leader should know about the registrant?
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Contact Information in Case of Emergency
Please do not use previous "Parent/Guardian" information as emergency contact information. The parent will be contacted first.
Emergency Contact 1
*
First Name
Last Name
Contact Number 1
*
-
Area Code
Phone Number
Relation to camper
*
Emergency Contact 2
*
First Name
Last Name
Contact Number 2
*
-
Area Code
Phone Number
Relation to camper
*
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Payment
Name of Registrant
*
First Name
Last Name
Legal Guardian Name Printed
*
First Name
Last Name
Legal Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Name of Registrant
*
First Name
Last Name
Legal Guardian Printed Name
*
First Name
Last Name
Signature of Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Adventure Camp Weeks (9AM-12PM)
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( X )
June 4th - June 6th
$
60.00
LeRoy Oakes Location
June 11th - June 13th
$
60.00
LeRoy Oakes Location
June 18th - June 20th
$
60.00
Johnson's Mound Location
June 25th - June 27th
$
60.00
LeRoy Oakes Location
July 9th - July 11th
$
60.00
LeRoy Oakes Location
July 16th - July 18th
$
60.00
LeRoy Oakes Location
July 23rd - July 25th
$
60.00
Johnson's Mound Location
I would like to support a kid to attend Adventure Camp on scholarship for a week
$
60.00
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Enter coupon
Apply
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Submit
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