2025 Summer Camp Registration

Buckle My Shoe Learning Academy’s Summer Camp Registration Form

June 30, 2025-August 22, 2025
Students Information
Camper’s Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age*
Do you have a voucher/childcare subsidy?*

YesNo
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Allergies*
Special Needs*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Let the fun begin! Our campers will enjoy Arts & Crafts , Dance, STEM, Indoor/Outdoor Activities, Water Fun, Field Trips (TBA), and more!

Camp Hours: 8:00am-4:00pm | Aftercare: 4:00pm-6:00pm

Dress Code: Campers should be dressed in light, comfortable play clothes and sneakers. NO SANDALS, CROCS, FLIP FLOPS, OPEN-TOED SHOES!

Food: Breakfast, lunch, and snacks are included. WE ARE A NUT FREE FACILITY! If you choose to send lunch and/or snacks for your child, please make sure it is nut-free and snacks must be in a store bought package with the listed ingredients.

Payment Policy: Payments are due on the Wednesday before the week of service. A $25 late charge will be applied thereafter with an additional $5 per day. Payments can be made by Money Order payable to Buckle My Shoe Learning Academy or through the Brightwheel platform.

Fees: $75 Registration | $285 per week | Aftercare $50 per week | $1.00 per minute will be charged for late pickups.

Please Note: Buckle My Shoe Learning Academy reserves the right to suspend or dismiss any child who displays unacceptable behavior that is deemed disruptive to a positive camp environment. No refunds will be given for suspension or removal from camp.

Waiver: I, on behalf of my child, acknowledge that participation in the above event is voluntary, and that I, on behalf of my child accept and assume all risk of injury, both known and unknown, while participating in the event. In consideration of being allowed to participate, I and my child voluntarily and expressly release, indemnify, forever discharge and hold harmless Buckle My Shoe Learning Academy, LLC and employees from any and all liability, claims, demands, causes, of rights of action, whether personal to me, my child, or a third party, which are in any way connected with participation in this activity, including those allegedly attributable to negligent acts or omissions. Also, I give permission for my child's picture to be taken and used in any Buckle My Shoe Learning Academy's promotional materials. I understand that if I do not want my child's picture to be taken or used in any way, I must notify the Director in writing. ACKNOWLEDGMENT: I hereby acknowledge that I have read the entire statement that came in this registration form and I accept all the terms and conditions therein.
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Pick-up Authorization Contacts

I authorize the following person(s) to pickup my child from Buckle My Shoe Learning Academy at the end of the day. I UNDERSTAND THAT I SHOULD NOTIFY THE COUNSELOR AND/OR DIRECTOR THAT SOMEONE ELSE IS PICKING MY CHILD UP ON A SPECIFIC DAY.
Name*

First NameLast Name
Relationship to child*
Phone Number*
Please enter a valid phone number.
Name

First NameLast Name
Relationship to child
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship to child
Phone Number
Please enter a valid phone number.
Parent/Guardian Signature*

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Buckle My Shoe Learning Academy’s Summer Camp Registration Form

Students Information

Pick-up Authorization Contacts