Spring Break Day Camp

Spring Break Day Camp
Camper's Information
Camper's Name

First NameLast Name
Age
Gender
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Shirt Size

Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult Large
What day of camp are you attending?

March 19thMarch 20thMarch 21st
Parent/Guardian Information
- The parents/guardian listed below will be the authorized person to pick-up the child after the camp.
- The parents/guardian listed below will also be the primary emergency contact person.
Name

First NameLast Name
Relation
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relation
Phone Number

Area CodePhone Number
Medical Information
Does the child have any allergies? If yes, please list them below:
Does the child have any current medical conditions? If yes, please list them below:
Payment Details
I understand that a $50 deposit will be required to hold my spot in day camp. I understand that one day of day camp is priced at $125, two days is $225, and three days is $325. Payments can be made via Zelle to dianefl1013@yahoo.com, or by cash or check.
Authorization
- I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached. I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
- I released the organizers, coaches, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment.
- I confirm that all information given in this form is true, complete, and accurate.
Parent/Guardian Signature

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Spring Break Day Camp

Camper's Information

Parent/Guardian Information

Medical Information

Payment Details

Authorization