PEBC Winter Day Camp Registration

Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade in 2025-2026 School Year:*
YesNo
Allergies/Health Concerns:*
February 16thMarch 12thMarch 13thApril 3rd
Yes

Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade in 2025-2026 School Year:*
YesNo
Allergies/Health Concerns:*
March 12thMarch 13thApril 3rd
Yes

Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade in 2025-2026 School Year:*
YesNo
Allergies/Health Concerns:*
March 12thMarch 13thApril 3rd
Yes

Child's Name*

First NameLast Name
Birth Date

MonthDayYear
Grade in 2025-2026 School Year:*
YesNo
Allergies/Health Concerns:*
March 12thMarch 13thApril 3rd

Family Information
Parent/Guardian's Name*

First NameLast Name
Contact Phone Number*
Format: (000) 000-0000.
E-mail Address*
example@example.com

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Format: (000) 000-0000.
Relationship to Child/Children*

YesNo
When?
How did you hear about our scholarship program?
Big BuddiesHeron Lake Caring Connections
How would your child benefit from being at a Wild Compass camp?
YesNo
Please list any financial circumstances that you would like to have considered as a basis for awarding this scholarship.
Is there anything else you would like for us to know?

Payment

School's Out Day Camp Payment

March 12th

8:30 to 3:00

$50.00 Quantity

March 13th

8:30 to 3:00

$50.00 Quantity

April 3rd

8:30 to 3:00

$50.00 Quantity

Enter coupon

Total

$0.00

Credit Card

Should be Empty: