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Summer Camp Registration
Child Information
Child's Full Name
(Required)
Gender
(Required)
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
Hidden
Start of Camp Date
MM slash DD slash YYYY
Hidden
# of Days Alive
Hidden
Age
Child Lives With:
(Required)
Approximate Drop-Off Time
(Required)
Approximate Pick-Up Time
(Required)
Please enter child's date of birth to continue.
Your Child Is Not Eligible For This Camp
Your child must be age 5 by September 1st of this year.
Your Child Is Not Eligible For This Camp
Your child cannot already by 11 years old by September 1st of this year.
Parent / Guardian Information
Parent / Guardian Full Name
(Required)
Relationship To Child
(Required)
Address
(Required)
Street Address
Address Line 2
City
ZIP Code
Home Phone
(Required)
Cell Phone
(Required)
Personal Email
(Required)
Employer / Business Name
(Required)
Employer / Business Address
(Required)
Work Email
(Required)
Typical Work Days & Hours
(Required)
Custody Assigned To:
(Required)
Enter Additional Parent / Guardian
(Required)
Yes
No
Additional Parent / Guardian Information
Parent / Guardian Full Name
(Required)
Relationship To Child
(Required)
Address
(Required)
Street Address
Address Line 2
City
ZIP Code
Home Phone
(Required)
Cell Phone
(Required)
Personal Email
(Required)
Employer / Business Name
(Required)
Employer / Business Address
(Required)
Work Email
(Required)
Typical Work Days & Hours
(Required)
Medical / Emergency Information
I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted:
Doctor's Name
(Required)
Address
(Required)
Phone
(Required)
Additional Doctor's Name
Address
Phone
Hospital Preference
(Required)
Hospital Address
Primary Insurance Company
(Required)
Plan
Policy Number
(Required)
Policy Holder's Name
Group Number (if applicable)
Secondary Insurance Company
Plan
Policy Number
Policy Holder's Name
Group Number (if applicable)
Please list any allergies, special medication or dietary needs, or other areas of concern:
Emergency Care Plan Instructions (if applicable)
Emergency Contacts:
The following people may be contacted and are authorized to remove the child from the facility in the case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:
Emergency Contacts
Name
Relationship to child
Home Phone
Cell Phone
Add
Remove
Summer Camp Selections
Please Choose The Weeks You Want Your Child To Attend
Week 1: May 26-31, 2024 Imaginative Inventions
Week 2: June 3-7, 2024 Cooking Around The World
Week 3: June 10-14, 2024 Mystery Magic
Week 4: June 17-21, 2024 Candy Chemistry
Week 5: June 24-28, 2024 Disney Inspired Science
Week 6: July 1-5, 2024 Olympics
Week 7: July 8-12, 2024 SLIMEology
Week 8: July 15-19, 2024 Space Explorer
Week 9: July 22-26, 2024 Crazy Chemistry
Week 10: July 29- August 2, 2024 Science Of Art (STEAM)
Will your child be attending Aftercare?
(Required)
$10 fee per week
Yes
No
Weekly Camp Fee
Weekly Materials Fee
Hidden
# of Weeks For Weekly Camp Fee
(Required)
Hidden
# of Weeks For Weekly Materials Fee
(Required)
Camp Fee Total
Materials Fee Total
Weekly Aftercare Fee Total
Price:
$10.00
July 4th Discount
Price:
June 19th Discount
Price:
Total
Payment Information
Credit Card
(Required)
Card Details
Cardholder Name
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