Summer Camp at Blue Giraffe Art Studio
4545 42nd Street NW, Washington DC 20016
CHILD INFORMATION:
Child Name
*
First Name
Last Name
Birthday
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Emergency Contact #1 (Other than primary contact)
*
First Name
Last Name
Emergency Contact #1 Phone Number
*
-
Area Code
Phone Number
Emergency Contact #2 (Other than primary contact)
*
First Name
Last Name
Emergency Contact #2 Phone Number
*
-
Area Code
Phone Number
MEDICAL INFORMATION
Medical Concerns; Allergies; Special needs: (physical; developmental; behavioral/emotional; sensory). This information helps our staff to do their best to accommodate all of our students particular needs.
Authorization for Medical Treatment: In the event that parents/guardians named on this form cannot be reached, I authorize officials of the Blue Giraffe Education Center to consent on my behalf, to provide emergency treatment for my child.
*
I Agree
Signature
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Week #1
Week #2
Week #3
Week #4
Week #5
Week #6
Please indicate the dates if you are choosing camp by days
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Regular Week 9:00am - 1:00 pm
$
390.00
How Many Weeks
Second Child 10% off
$
351.00
How Many Sessions
Week #2 July 5-8
$
312.00
Camp By Days
$
96.00
Please
Quantity
Camp By Days Second Child
$
86.00
Quantity
Total
$
0.00
Credit Card
Signature
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