BASE Sports Summer Camp Registration Form

BASE Sports Summer Camp Registration Form
Camp Location:
Health Sciences Charter School
1140 Ellicott St, Buffalo, NY 14209
Camp Type: Sports Summer Camp
Ages Accepted: 5-12 years old
BASE Sports Summer Camp focuses on physical activity, teamwork, confidence, enrichment, and fun.
Camp Activities Include:
- Flag Football
- Volleyball
- Tag
- Baseball
- Tumbling
- Golfing
- Soccer
- Dancing
- Walking
- Group Games
- Weekly Field Trips
- 5-10 Hours of Enrichment Per Week
- And More
Camper Information
Child's Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Grade Entering:
T-Shirt Size: Youth XS / Youth S / Youth M / Youth L / Youth XL / Adult S / Adult M / Adult L
Date:

MonthDayYear
Date
Please select camp weeks
Parent/Guardian Information
Parent/Guardian Name:
Phone Number:
Format: (000) 000-0000.

Email Address:
example@example.com
Home Address:
Emergency Contact Name:
Emergency Contact Phone Number:
Format: (000) 000-0000.
Relationship to Child:
Medical Information
Does your child have any allergies? Yes / No
If yes, explain:
Does your child take medication? Yes / No
If yes, explain:
Does your child have any medical, behavioral, or physical needs we should know about? Yes / No
If yes, explain:
Child's Doctor/Clinic:
Health Insurance Provider:
Policy/ID Number:
Authorized Pickup
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Field Trip Permission
I give my child permission to attend weekly field trips with BASE Sports Summer Camp.
Parent/Guardian Initials:
Photo/Video Permission
I give BASE permission to take photos/videos of my child during camp activities for program memories, social media, marketing, and promotional use.

Yes / No
Parent/Guardian Initials:
Financial Agreement
Camp Tuition: $135 per week per child (Sibling discount (-$25)
Tuition payments are due every Monday morning before your child may attend camp. NO EXCEPTIONS.
Failure to make payment by Monday morning may result in your child being unable to participate in camp activities
until payment is received.
Payments made toward camp are non-refundable unless otherwise approved by BASE administration.
Parents/guardians are financially responsible for all weeks their child is registered to attend.
Returned payments and declined transactions may result in additional fees.
Payment Methods Accepted
Cash
Debit/Credit Card
Online Payment
Money Order
Parent Financial Agreement
I understand and agree to the following:
• Weekly camp tuition is $135 (Sibling discount (-$25).
• Payment is due Monday morning before camp begins.
• My child may not attend camp if payment has not been made.
• No exceptions will be made regarding weekly payment deadlines.
• I am responsible for keeping my child's account current.
Parent/Guardian Initials:
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Parent Agreement
I understand that BASE Sports Summer Camp is an active sports camp. My child will participate in physical activities
including sports, tumbling, dancing, walking, games, field trips, and enrichment activities.
I understand that injuries may occur during sports and physical activity. I agree to notify staff of any medical concerns,
allergies, or limitations my child may have.
I understand that children are expected to follow camp rules, respect staff, respect other campers, and participate
safely.
Parent/Guardian Signature:

My Products

Registration Fee

non-refundable, Non transferable, includes camp T-shirt

$35.00 Quantity

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

BASE Sports Summer Camp Registration Form

Camp Activities Include:

Camper Information

Parent/Guardian Information

Medical Information

Authorized Pickup

Field Trip Permission

Photo/Video Permission

Financial Agreement

Payment Methods Accepted

Parent Financial Agreement

Parent Agreement

My Products