Spring 2025 - PODS 5th and 6th Grade

Summer Day Camp Registration
Review descriptions for camps here!

DISCLAIMER: Due to the nature of our programs, which may involve various physical activities and an increased level of risk, we may face challenges in supporting students. While we are committed to providing a safe and enriching experience for all students, the level of supervision and individualized support required for children with specific behavioral or emotional needs may exceed our current staffing capacity. We encourage families to email us at education@pacificagarden.org to discuss their child’s needs with us in advance so we can assess whether our program is a suitable fit.

Please note that we reserve the right to unenroll a student if their behavioral challenges or supervision needs disrupt the class or exceed what our staff can reasonably provide. In such cases, parents or guardians will be required to withdraw their child from the program.
Student Information
View camp descriptions and details here and then choose the camp you want to register for below.

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Horse Camp 2August 18-21 | Ages: 11-14

$300.00

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$10.00

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Total

$0.00

Payment Methods

Credit Card

Apple Pay

ACH Bank Transfer

Camp Selection (Choose the class/classes that you selected above)

Horse Camp (Ages 7-10)Horse Camp (Ages 11-14)
Student's Full Name *
First and Last Name
Student's Preferred Name*
Type first name if it is the same as above.
Age*
Gender

MaleFemale
Parent/Guardian Information
Parent/Guardian Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I agree to receive Pacifica emails about news, events, and education activities.
Emergency Contacts
The parent or guardian completing this form will automatically be the first emergency contact. If you are not available, please list two additional contacts that we can call in case of an emergency.

Please notify this emergency contact of your child/dependent's camp dates and that they are listed as an additional emergency contact.
Please list TWO Emergency Contacts. Include their Name, Relationship, Phone Number*
Legal parents/guardians are contacted first whenever possible.*

In case of medical or surgical emergency, I hereby give permission to the Outdoor School Coordinator to arrange transport for my child, as named above, to the hospital for evaluation by a physician.
STUDENT HEALTH INFORMATION
Please provide any health information needed to maintain the health and safety of your child during their time at camp. Health information shared will remain confidential. Especially note any health, emotional, or physical problems that might require special staff planning such as food allergies, medications, or behaviors.
Please share any medical or health information that we need to be aware of.
Please check any that pertain to your child's health:*

Not Applicable (N/A)Asthma or other breathing problemsBowel/Bladder ProblemsDiabetesEmotional/Behavioral/Learning concernHay FeverHearing ProblemVision ProblemsMobility IssuesPhysical Injuries (recent)Seizure DisorderSkin ProblemsSleep WalkingOther
Please share any other information needed to best care for your child:
Applicable health concern needing treatment, any chronic or recent illness, surgical procedure, activity restrictions or concerns, and any other needs we should know about (privacy needs, anxiety/nervousness, bed wetting etc.).This information is confidentially shared with Pacifica and camp staff to accommodate your child's needs.
OVER-THE-COUNTER (OTC) MEDICATION

AUTHORIZATION FORM
For the relief of minor health problems that might temporarily affect your child’s comfort while at camp, there is a small supply of common over-the-counter medications at the site. Do not send these medications with your student.

THE HEALTH HISTORY FORM IS CHECKED FOR ALLERGIES BEFORE ANY MEDICATION IS GIVEN.

Medications available at Outdoor School are:
- Alcohol Wipes Aloe Vera gel – burns/sunburns
- Antibiotic Cream/Ointment
- Anti-diarrheal (Loperamide)
- Antihistamines (Benadryl, Chlor-Trimeton, Loratadine)
- Calcium Carbonate for indigestion (Tums)
- Cream for athlete’s foot or ringworm (Lotrimin or Tinactin)
- Cream for Chapped Skin Cream for itching (Hydrocortisone, Benadryl, Calamine lotion)
- Cough Drops Glucose for diabetic emergency
- Eye Drops
- Insect repellent Lotion
- Milk of Magnesia Non-aspirin pain/fever relievers (Tylenol and Advil)
- Soap for poison oak (Tecnu)
- Sunscreen
NOTE: Brand names have been listed but their generic equivalent or the same medication of a different brand may be substituted. We do not stock chewable or liquid pain relievers.

Select whether or not you would like your child to be able to receive over-the-counter (OTC) medication if needed. If this list contains medication you do not want your child to receive, please select the third option "some" and then explain your reasons below.
Authorization to administer OTC medications while at Outdoor School*

YesNoSome
Please list any specific instructions for OTC medication:
Any known drug allergies?*

YesNo
Please list any known drug allergies:
Dietary Restrictions or Food Allergies

This information will be shared with our food chef. We can accommodate most dietary needs including vegetarian, vegan, and gluten-free. We will have a variety of food for your child to ensure that there is something they will like.
Please list any dietary restrictions or food allergies: *
Type "NONE" if there are no dietary restrictions or allergies.
Liability Release
We have started a new system for liability and media release forms, so you will only need to fill it out once for yourself or your dependent. These liability forms will be active for one year.

All participants must sign our release forms before attending any event at Pacifica. Failure to sign the release form may result in the resignation of your registration.

CLICK HERE TO FILL OUT YOU OR YOUR CHILD'S LIABILITY FORM
Payment and Refund Policy: Full payment at time of registration is required. Up until two weeks prior to the start of the event, you will receive a full refund (minus a $10 service charge) should you need to cancel your registration. However, cancellations made after this two-week time frame are nonrefundable. Should Pacifica cancel the event, all participants will receive a full refund or credit toward future classes.
DISCLAIMER & PARTICIPATION AGREEMENT

By enrolling your child in our programs, you acknowledge and agree to the following terms:

Our programs may involve physical activities and an increased level of risk. While we strive to create a safe and enriching environment for all students, our staffing and resources may not allow for the level of supervision and individualized support required by some children with specific behavioral or emotional needs.

We encourage all families to contact us in advance at education@pacificagarden.org to discuss their child’s needs so we can determine whether our program is an appropriate fit.

By proceeding with enrollment, you understand and agree that:
- If your child’s behavior is consistently disruptive to the class, or
- If their need for supervision exceeds what our staff can reasonably provide,
- We reserve the right to cancel their enrollment, and you will be required to withdraw your child from the program.
These measures are in place to ensure a safe and supportive experience for all students.
Date*

MonthDayYear
Date
Parent Full Name*

First NameLast Name
Should be Empty:

Summer Day Camp Registration

Student Information

Payment Methods

Parent/Guardian Information

Emergency Contacts

STUDENT HEALTH INFORMATION

OVER-THE-COUNTER (OTC) MEDICATION

Dietary Restrictions or Food Allergies

Liability Release