Summer Care Application Form
Full name of child
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
Date
Guardian's Name
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
People authorized to pick up child (Name and Phone Number)
Person to call in case of emergency
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
How often are you wanting your child to participate?
1x a week
2x a week
3x a week
5 days a week
What days are you interested in
Monday and Wed
Tues and Thurs
Mon, Wed, Fri
Mon- Friday
Is there a configuration of days that was not listed above? Please enter below
Are you interested in the half day or full day option?
4 hour half day 10-2 $50 a day
4 hour half day 9-1 $50 a day
Full day option 9:30-3:30 $350 a week for 5 days
Will you be needing financial assistance?
Yes
No
Will you be with us the entire summer or just a couple weeks here and there?
entire summer
one week
multiple weeks
Signature of parent
Submit
Submit
Should be Empty: