Camp Five Ducks 2024 Registration Form

Registration
Child Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age by June 24th, 2024*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Race/Ethnicity*

White (Non-Hispanic or Latino)White (Hispanic or Latino)Black (Non-Hispanic)Black (Hispanic or Latino)AsianAmerican Indian/ Native AlaskanNative HawaiianMultiracialPrefer not to Answer
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Work Number
Please enter a valid phone number.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Select Weeks Full-Time $155 Weekly*

All 7 WeeksWeek 1 (July 1st-July 5th)Week 2 (July 8th-July 12th)Week 3 (July 15th -July 19th)Week 4 (July 22nd - July 26th)Week 5 (July 29th-August 2nd)Week 6 (August 5th -August 9th)Week 7 (August 12th - August 16th)Not Attending Full Time
Select Weeks: Part-Time (3 ONLY Days) at $125 per Week*

Attending All 7 WeeksWeek 1 (July 1st-July 5th)Week 2 (July 8th-July 12th)Week 3 (July 15th -July 19th))Week 4 (July 22nd -July 26th)Week 5 (July 29th-August 2nd)Week 6 (August 5th -August 9th)Week 7 (August 12th - August 16th)Not Attending Part Time
What Part-Time Days will your child attend?

MondayTuesdayWednesdayThursdayFriday
Does your child have any allergies?*

YesNo
Does the child have any chronic illness, behavorial or medical conditions? If yes, please describe.*
is your child on any medications?*

YesNo
I give Five Ducks Academy and Five Ducks Foundation Permission to photograph and/or videotape my child for public relations and/or marketing purposes.*

YesNo
I authorize camp staff in any emergency situation to administer basic first aid for health or welfare reasons.*

YesNo
My child is allowed to watch PG movies.*

YesNo
Discipline Policy see parent handbook for more details: 1. Verbal Warning and the warning will be documented. Parents will be notified at pick-up time. 2. Written Warning: A report of the incident will be written, and parents will be notified. 3. Suspension: Suspension from the camp program will be an automatic consequence for behavior such as fist fighting, physical/verbal coercion and destruction of property. No refunds or credits will be given for time missed due to disciplinary action.*

YesNo
How did you hear about us?*

FacebookInstagramReferred by SomeoneAttended Last YearOther
We are looking forward to having a fun summer! Once the registration form is submitted you will receive a confirmation with further instructions including payments. Please note a $75.00 registration fee is required and is non-refundable.
Thank You!

My Products*

Summer Camp Registration

$75.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature*

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Registration

Child Information

Payment Methods