Summer Camp Registration Form

Summer Camp Registration
Camper Information
Camper's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Age
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the camper have any allergies, chronic illness, special needs or medical conditions? If yes, please describe.
Is the camper prescribed an inhaler or any other medication? If yes, please explain any instructions.
Authorized pick up list (Please include name and number):
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT CONFIRMS MY CAMPERS PARTICIPATION IN SUMMER CAMP PROVIDED BY LISHA'S HELPING HANDS.
Date

MonthDayYear
Date
Signature

Clear

Parental consent for participation in off campus field trips:
Parental consent for medical treatment if needed (CPR and/or prescribed medication):
In the event of an emergency, I authorize the camp to seek medical treatment and be transported to:
Parental consent to capture and release photos of camper:
My Products
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Registration FeeSibling Discount does not apply to registration fee! Registration fee is per camper.
$15.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Summer Camp Registration