Summer Camp Registration Form 2021

Summer Camp Registration Form 2021
Camper Information
Child #1 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade entering in Fall 2021 *
Would you like to register another child? *

Yes No
Child #2 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade Entering Fall 2021 *
Would you like to register another child? *

Yes No
Child #3 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade Entering Fall 2021 *
Would you like to register another child? *

Yes No
Child #4 Name *

First Name Last Name
Child's Age *
Child's Birthdate *

Month Day Year
Date
What is your child's gender?
What pronouns does your child use?

They/Them She/her He/him Other
Grade Entering Fall 2021 *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian #1 *

First Name Last Name
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Best Phone to Use During the Day *

Cell Home Work
Parent/Guardian Email (This is the email that will be used for primary communication.) *
example@example.com
Does your child have a Parent/Guardian #2? *

Yes No
Parent/Guardian #2 Name *

First Name Last Name
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Best Phone to Use During the Day *

Cell Home Work
Email
example@example.com
Emergency/Medical Information
In case of an emergency, parents/guardians will be contacted first. Please list the names & numbers of two additional contacts who will be called if parents/guardians cannot be reached.
Emergency Contact #1 *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Child/Children *
Emergency Contact #2

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Child/Children
Please list the people who are authorized to pick up your child/children from camp (changes can be made to your list later) *
Summer camp staff need to be aware of any medical issues (such as allergies or diabetes) as well as any physical, social or congnitive challenges that your child/children might have. All information will be kept confidential.
Would you like to explain any medical issues or challenges for your child/children? *

Yes No
Please do so here.
Child/ren's Physician
Phone Number

Area Code Phone Number
Membership Status
Are you a Member of Strawbery Banke Museum? *

Yes No I don't know
Is the child's parent/guardian on active duty in the military?

Yes No
Choose your Camps
Click the camps for which you are registering:

Anchors Aweigh Waiting List, ages 6-8 (June 28 - July 2, 2021) All Hands on Deck awaiting List, ages 9-12 (June 28 - July 2, 2021) Jr. Roleplayers: Modern Age Waiting List, ages 12 -17 (July 5 - 16, 2021) Colonial DIY Waiting List, ages 6-9 (July 12 - 16, 2021) History Alive I Wait List, ages 6-9 (July 19 - 23, 2021) History in Play: Growing Up Colonial Waiting List, ages 9-12 (July 19 - 23, 2021) Traditional Trades Waiting List, ages 9-12 (July 26 - July 30, 2021) Jr. Roleplayers: The New Republic Waiting List, ages 12-17 (July 26 - August 6, 2021) Archaeology Adventure Waiting List (August 2 - 6, 2021) Dig the Past Waiting List, ages 6-9 (August 9 - 13, 2021) Jr. Interpreters: Archaeology Waiting List, ages 13+ (August 9 - 13, 2021)
If needed, please clarify which children are doing which camps.
Release and Consent
Please list the full name(s) for each child attending camp. *
I/We authorize Strawbery Banke Museum staff to arrange for emergency care for my/our minor child/children at a local hospital, as the staff deems necessary. I/We authorize hospital personnel to provide emergency medical treatment for my/our child/children.

I/We wish that my/our child/children participate in camp program(s) which is/are organized by Strawbery Banke Museum during the summer of 2021. I assume all the risks of injury and loss arising or resulting from my/our child's/chldren's participation, hereby releasing and holding harmless the Museum, its employees or agents from liability for any such injury or loss.

Unless otherwise informed, I/We allow our child to appear in photographs taken for use in Strawbery Banke Museum publications, publicity and social media. I also agree to allow photographs from camp to be available on a password protected site, to which only fellow camp families have access.
Please type your name(s) into the box below. By doing so, you are certifying that you are the parent and/or legal guardian of the minor participant(s) listed above, and you understand and are in agreement with the waivers indicated above. *
Summer Camp Payment

A deposit is required to secure your space in camp. You can opt to pay in full now using the form below or skip payment here and receive an invoice via email that will allow partial payment. If you want to skip payment, scroll to the bottom and hit "submit" to send your form.
Click the down arrow next to the category that applies to your membership status.
Categories: All

All

Non-Members
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Non-Members

Jr. Roleplayers: Modern Age (July 5 - 16, 2021) ages 12 - 19 $ 580.00

Quantity

Jr. Roleplayers: The New Republic (July 26 - August 6) ages 12 - 18 $ 580.00

Quantity

Total $ 0.00
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Summer Camp Registration Form 2021

Camper Information

Parent/Guardian Information

Emergency/Medical Information

Membership Status

Choose your Camps

Release and Consent

Summer Camp Payment