Southlands Jumpstart Camp Enrollment Form

Southlands Jumpstart Camp Enrollment Form

Thank you for joining us for a summer of Southlands fun! Please complete one form for each child you are enrolling for jumpstart camp. Camp will run from August 17th-21st from 9 am each day to 1pm. Please note that spaces are limited. if you have any questions, don't hesitate to reach out to our office at (845) 876-4862.
Camper's Information

Jumpstart Camp is for children between the ages of 4-7. Please keep this in mind while filling out the following information.
Camper's Name

First NameLast Name
Grade
Date of Birth

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this the camper's first time at Southlands?
Is there anything in particular you would like your child to learn while they are attending Jumpstart camp? Any skills you think they should brush up on?

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.
Primary Contact Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Relation
Secondary Contact Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Relation

Medical Information

Camper's medical information is only available to our primary staff.
Primary Physician name
Primary Physician Contact
Insurance Company Name
Member ID
Subscribers Name
Policy #
My child has permission to engage in all camp activities
If no, please elaborate on restricted activities
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 takes any medication? If yes, please list them below and explain its purpose:
Parents must submit a current immunization record demonstrating compliance with New York State immunization requirements for school-age children. Records must be received prior to the start of camp. Upload here or contact our office at (845)876-4862 to submit another way.

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Camper's Information