Sample Summer Camp Registration Form

Summer Camp Registration. June 30-August 22, 2025

WAY Christian Summer Program and Camp, 45 Academy Street, Downtown Newark, NJ Website: http://www.polkadotministriesedu.org Email: waypolkadotministriesedu@gmail.com
FYI

WAY Christian Summer Program and Camp is a licensed camp and will run from June 30th to August 22nd, from 8:00am to 5:00pm that will focus on the arts and academics.

WHAT YOU CAN ANTICIPATE

Our program is specifically to tutor in the academic fields of reading and math and guarantee growth in these areas. Campers will have fun while improving their academic skills. Campers will also have Bible class. The weekly camp fee inlcudes a T-shirt, backpack, and all field trips and activities.

We are located in the heart of the city of Newark. Thus, we will also be taking neighborhood walks to the library, museum, Ballantine House, and doing many other activities that will enrich your child's summer. You will receive a summer itinerary/schedule of weekly activities prior to the beginning of camp, posted on our website or can be picked up at our location at 45 Academy Street, Suite 200.
Camper Name
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Camper's Information
Address*
City*
State*
Zip*
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Birth Date*

MonthDayYear
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Church Information
Church you attend
Church City
Email Confirmation
Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)
Other Information
Is camper free from infectious desease or conditions?*

YesNo
Are immunications up to date?*

YesNo
Date of last tetanus shot*
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
List all medications, both prescribed and over the counter.*
Payment Information

$50 Registration Fee Due
Method of Payment*
prevnext( X )
(Paypal or Credit Card)Registration Fee+Processing Fee$201.50

Send a Check $200 (No Processing Fee)$200.00
Initial registration includes camp registration and camp fee for the first week.
If paying with PayPal you will be redirected to PayPal once you hit submit. You can either pay with credit card, or PayPal. There is a $1.50 processing fee for using this option. The remaining balance is due anytime before their week of camp. If you have any questions feel free to contact Shonna Huezo at 551-689-3101.
If paying with a check, please send the registration fee as soon as possible. You can pay multiple registration fees with one check. In memo, please put the camper(s) name. The registration fee includes the camp fee for the first week. Camp fees for any consecutive weeks desired, have to be paid prior to the camp week inorder to secure camper's slot, due to limited space. If you have any questions feel free to contact Shonna at 551-689-3101.
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)*
- Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 1 week.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. The camp carries secondary insurance. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites. I authorize The Springs to use my camper's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the camp.
Signature*

Clear
Electronic signature, please initial*
Should be Empty:

Summer Camp Registration. June 30-August 22, 2025

Camper Name

Camper's Information

Parent or Legal Guardian Information

Church Information

Email Confirmation

Other Information

Payment Information

Camper Release