Day Camp Registration Form

Summer Therapy Camp

Ready, Set, School!
Camper's Information

Personal & Health & Contact
Name

First NameLast Name
Birth Date

MonthDayYear
Age (at time of camp)
Grade (entering this fall)
T-shirt Size:
Any medical alerts?
List Any Allergies and Dietary Restrictions
Medications & Frequency
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Guardian Information

(All correspondence and and invoices will be sent to this person)
Name

First NameLast Name
Email
example@example.com
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Occupation
Relationship with the Camper
Emergency Contacts and Authorized Pick Up Persons
Emergency Contacts and Authorized Pick Up Persons
Program Information

The program is a 6-weeks program. Parents can choose to enroll 1 day or 2 days per week at a discounted rate. Materials and snacks will be provided by the program. Parent is responsible for notifying about any medical alerts and/or allergies. Program must be prepaid prior to the first day of the program. Payment plans available. REFUNDS: $100 non-refundable deposit to reserve spot. Remaining balance charged weekly every Friday for upcoming weeks. Cancellations more than 14 days before start date: Refund minus $100 registration fee, cancellations between 7–14 days before start date:50% refund, cancellations less than 7 days before start date: No refund. Missed Days / Absences: Because this is group-based: Make-up options may be offered only if space allows.
Select Camp Day(S)
Payment Type
Signature
Terms and Conditions
Date

MonthDayYear
Date
Should be Empty:

Summer Therapy Camp

Camper's Information

Parent / Guardian Information

Program Information