Spring Break Camp Registration Form

Spring Break Camp Registration Form

Register for Pelican Therapy’s upcoming camp
Participant's Full Name*

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Does the participant have any allergies or medical conditions we should be aware of?
March 16 Full dayMarch 17 Full dayMarch 18 Full dayMarch 19 Full dayMarch 16 Half dayMarch 17 Half dayMarch 18 Half dayMarch 19 Half day
How did you hear about this camp?
Payment: if paying via card online $3 processing fee applies if check please drop at office to reserve spot no fees applied
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Full Day camp
$53.00 Quantity

Half Day camp
$33.00 Quantity

Total

$0.00