School Break Camp Registration
Gathering Student Information
Student Full Name
*
First Name
Last Name
Grade
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Student School
*
Age
*
Parent Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Information
The parents/guardian listed below will be the authorized person to pick-up the child after the camp. The parents/guardian listed below will also be the primary emergency contact person.
Parent 1 Information
*
Parent 2 Information
Medical Information
Does the child have any allergies? If yes, please list them below
Does the child have any previous injuries? If yes, please explain them below
Does the child have any current medical conditions? If yes, please list them below
Does the child take any medication? If yes, please list them below and explain its purpose
How did you hear about us?
*
Internet
Friend
Family
School
Flyer
Other
I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached.
I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
I released the organizers, coaches, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment.
I confirm that all information given in this form is true, complete, and accurate.
Parent/Guardian Signature
*
Additional Notes (medical conditions, special requirements, etc.)
Payment Details
My Products
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February Break Camp
2/16-2/19
$
199.00
Quantity
1
2
3
4
5
6
7
8
9
10
Spring Break Camp
April 6-9
$
199.00
Quantity
1
2
3
4
5
6
7
8
9
10
February Daily Drop In
One Day of Camp
$
50.00
Quantity
1
2
3
4
April Daily Drop In
One Day of Camp
$
50.00
Quantity
1
2
3
4
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Register
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