Summer Enrichment Camp Application

Southern Angels Exceptional Ed Consulting

Summer Enrichment Camp 4 All

4243 Lebanon Pike, Suite C, Hermitage, TN 37076-2170 info@southernangelscomprehensive.com 615-600-5107

***Please complete a form for each child***
Full Name*
Date of Birth MMDDYYYY*

MonthDayYear
Pre-Kindergarten 4Kindergarten1st2nd3rd4th5th6th7th8th
Name*
Phone Number*
Email Address*
example@example.com
Address*
YesNo
YesNo
YesNo
YesNo
Medical & Emergency Information
Allergies Medical Conditions*
Medications Required During Camp*
Doctor's Name*
Emergency Contact (Other than Parent/Guardian):
Name*
Phone Number*
Relationship*
YesNo
If yes please type yes and upload; if no, please type N/A.*
File Upload

Cancelof
YesNo
If yes please describe all behaviors and triggers; if no, please type N/A*
Is there anything else we should know to best support your child*
I agree to pay camp fees in the amount of $180.00 for the 1st child and $170.00 for the 2nd child for the week of June 1-5, 2026 by Friday May 29, 2026.I agree to pay the $7.00 application fee per child by Friday May 29, 2026.I agree to the payment policy and understand that my child cannot attend camp without full payment.I agree that all fees are non-refundabled.I agree to attend the mandatory meeting at Southern Angels, 4243 Lebanon Pike, Suite C., Hermitage, TN 37076 on Thursday, May 16, 2026 from 10:00AM-11:30AM.
Signature of Parent Guardian*

Clear
Date

MonthDayYear
Date
Submission Instructions Please return this completed form via Jot. If you have any questions feel feel free to: Email: info@southernangelscomprehensive.com Or drop by the office at: 4243 Lebanon Pike, Suite C, Hermitage, TN 37076-2170
Summer Enrichment Camp options:
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Summer Break Child 1
June 1-30, 2026 from 8:00-3:00 p.m.

$180.00 Quantity



Summer Break Child 2
June 1-30 2026 from 8:00-3:00 p.m.

$170.00 Quantity



Before Care: June 1-30, 2026
Before 7:00AM-8:00 AM

$30.00 Quantity



After Care: June 1-30, 2026
After Care 3:00PM-4:00PM

$30.00 Quantity



Before & After Care: June 1-30, 2026
Before & After Care

$55.00 Quantity



Summer Enrichment Application Fee
Per Child

$7.00 Quantity



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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