Summer Camp Registration Form

Summer Camp Registration Form

Located at Room To Bloom 81 Bridge St. Beverly, MA
Childs Full Name

First NameLast NameNickname?
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Parent/Guardian #2 Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
How did you hear about us?
Please Specify

Please list two emergency contacts in the event we cannot reach you:

Rows	Full Name	Address	Contact Number
1
2

The Following people have permision to pick my child up from camp:

Rows	Full Name	Contact Number
1
2
3
4
5

Please Check off the week(s) you would like to register for (all weeks include a special performance for family and friends on Thursday @ 3:45):
Any other themes/dates/times you would like to see in the future?

Pediatrician

Namephone number
Preferred Local Hospital:
hospital
Does your child have any allergies we should be aware of?
If yes, please describe:
Does your child have any medical conditions we should be aware of?
If yes, please describe:

Please list any other information your would like us to know about your child:
Room To Bloom Waiver - MUST FILL OUT AND SIGN PRIOR TO FIRST DAY OF CAMP
I, the undersigned parent/legal guardian of blanks* (child's name)
authorize the child’s participation in Wiggles and Giggles Camp and all related activities. The camp staff has permission to seek medical attention for the child in the event of an accident or sickness. Wiggles and Giggles has permission to take and use pictures, slides, and/or audio-video tapes of the child taken while he/she is involved in activities for marketing and public relations purposes. I recognize and acknowledge that there are certain risks of physical injury to the child in the program. I, the child, and my insurer, hereby release, waive, relinquish, and discharge Wiggles and Giggles in conjunction with Room to Bloom from any and all claims, demands, action, or causes of action whatsoever, arising out of or related to any loss, damage, or injury that may be sustained by the child as a result of the child’s participation in the program. I acknowledge that I understand that this is a full release and that I have voluntarily waived my rights and those of the child and insurer. I further understand that my child's place in the camp program is not confirmed until all forms and payments have been made.
Date

MonthDayYear
Date
Choose the week(s) you are registering for:
prevnext( X )
Camp Week 1
7/8-7/11 Summer Fun!

$275.00 Quantity



Camp Week 2
7/15-7/18 Around the World

$275.00 Quantity



Camp Week 3
7/22-7/25 Animal Jam!

$275.00 Quantity



Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
Should be Empty:

Summer Camp Registration Form

Choose the week(s) you are registering for:

Payment Methods