Summer Camp Detailed Registration Form

Camper's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Gender

MaleFemaleOther

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, or medical conditions? If yes, please describe.

Is the camper prescribed an inhaler? If yes, please explain any instructions.

🌟 Little Luminaries Summer Camp
Statement of Payment

Thank you for registering your child for Little Luminaries, a therapeutic summer camp focused on emotional growth, creativity, and connection!

Camp Schedule:
🗓 Dates: Wednesday, Thursday & Friday — Summer 2025
🕘 Times:

Wednesday & Thursday: 9:00 AM – 3:00 PM (Full Days)
Friday: 9:00 AM – 12:00 PM (Half Day Outdoor Adventure at Lake Needwood)

Tuition:

Total Cost: $250 per camper (covers all three days)

Includes two full days + one half day
Snacks, drinks, sunscreen, bug spray, camper T-shirt, and welcome gift bag included
All materials and activities are provided
Payment Details:

Payment is due at the time of registration to reserve your child’s spot.
Invoice will be sent upon regristration a split payment of 2 payments due before camp week. Invoices will be sent via simple practice.

Receipts and confirmation will be provided upon payment.
Important Note:
Only 6 spots are available to maintain a small, supportive environment. Campers will be supported by Perla Lay, LCPC, and a graduate-level intern trained in child mental health and group facilitation.

Thank you for trusting us with your child’s emotional wellness and summer fun! If you have any questions or concerns, feel free to reach out anytime.

Warmly,
Perla Lay, LCPC
Green Haven Healing

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Green Haven Healing during the selected camp. In exchange for the acceptance of said child’s candidacy by Green Haven Healing ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Green Haven Healing and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Green Haven Healing including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Green Haven Healing . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Summer Camp Registration

Camper Information