Healing Waters Summer Camp Registration Form 🎨🌞

Healing Waters Summer Camp Registration Form 🎨🌞

Please fill out the sections below to register your campers and provide necessary information.
Camper Information
Camper Information
Parent/Guardian Information
Parent/ Guardian Name

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Allergies (if any)
Medical Conditions (if any)
Current Medications (if any)
Physician Name and Phone
Authorized Pick-Up List

Authorized Pick-Up Persons

Permissions and Consent
I authorize the camp to seek emergency medical care for my child if necessary.
I grant permission for my child to be photographed or recorded for camp promotional purposes.
I give permission for my child to participate in all camp activities.
Payment Information
EARLY BIRD SPECIAL PRICES AVAILABLE UNTIL MAY 31!
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Session 2 : June 8 - 12
$115.00 Quantity



Session 3: June 15 - 18
$115.00 Quantity



Session 4: June 22 - 26
$115.00 Quantity



Session 5: June 29 - July 2
$115.00 Quantity



Session 6: July 6 - 10
$115.00 Quantity



Session 7: July 13 - 17
$115.00 Quantity



5-Session Packet +
$550.00 Quantity



Product Name
Free Quantity



Total

$0.00
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only
Notes (Office Use Only)
Please use PayPal Checkout as Preferred Method
Payment Methods

Fastlane Checkout

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

Contact Info

Payment Info
Should be Empty:

Please use PayPal Checkout as Preferred Method