Summer Care Interest Form

Summer Care Application Form
Full name of child

First NameMiddle NameLast Name
Gender

BoyGirl
Date of birth

MonthDayYear
Date
Guardian's Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
People authorized to pick up child (Name and Phone Number)
Person to call in case of emergency

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How often are you wanting your child to participate?

1x a week2x a week3x a week5 days a week
What days are you interested in

Monday and WedTues and ThursMon, Wed, FriMon- 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 day4 hour half day 9-1 $50 a dayFull day option 9:30-3:30 $350 a week for 5 days
Will you be needing financial assistance?

YesNo
Will you be with us the entire summer or just a couple weeks here and there?

entire summerone weekmultiple weeks
Signature of parent
Should be Empty:

Summer Care Application Form