Eastside Express Summer Camp
June 17th - August 2nd, 2024. Please only register one child at a time. ESX is open only to children ages 7-12. $5 per day. You must sign up for whole weeks, and sign up for a minimum of one week.
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
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Day
Please select a year
2024
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Year
School/grade child will be attending this fall
*
Enter Parent/Guardian #1 Information
Parent/Guardian #1
*
First Name
Last Name
Parent/Guardian #1 Phone
*
Email #1
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Enter Parent/Guardian #2 Information
Parent/Guardian #2
First Name
Last Name
Parent/Guardian #2 Phone
Email #2 (optional)
example@example.com
Address #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
IN CASE OF EMERGENCY
Emergency Contact Name
*
Emergency Contact Phone
*
Doctor's Name
Doctor's Phone
Known allergies
Preferred hospital
Additional comments
Week Selection & Payment
Weeks Registering For:
*
prev
next
( X )
WHOLE WEEK ONE (6/17 - 6/19)
Please select if you'd like your child to attend WEEK ONE. (No programming on 6/19)
$
20.00
WHOLE WEEK TWO (6/24 - 6/28)
Please select if you'd like your child to attend WEEK TWO.
$
25.00
WHOLE WEEK THREE (7/1 - 7/5)
Please select if you'd like your child to attend WEEK THREE. (No programming on 7/4 & 7/5)
$
15.00
WHOLE WEEK FOUR (7/9 - 7/12)
Please select if you'd like your child to attend WEEK FOUR.
$
25.00
WHOLE WEEK FIVE (7/15 - 7/19)
Please select if you'd like your child to attend WEEK FIVE.
$
25.00
WHOLE WEEK SIX (7/22 - 7/26)
Please select if you'd like your child to attend WEEK SIX.
$
25.00
WHOLE WEEK SEVEN (7/29 - 8/2)
Please select if you'd like your child to attend WEEK SEVEN.
$
25.00
Signature
*
Register
Should be Empty: