Camp Registration

1. Child(ren)'s Information
Child 1*
First Name Last Name
Birth Date*

Month Day Year
Gender*

MaleFemale
Weeks*

Week 1 (from June 30)Week 2 (from July 7))Week 3 (from July 14)Week 4 (from July 21)Full Summer
Child 2
First Name Last Name
Birth Date

Month Day Year
Gender

MaleFemale
Weeks

Week 1 (from June 30)Week 2 (from July 7)Week 3 (from July 14)Week 4 (from July 21)Full Summer
Child 3
First Name Last Name
Birth Date

Month Day Year
Gender

MaleFemale
Weeks

Week 1 (from June 30)Week 2 (from July 7)Week 3 (from July 14)Week 4 (from July 21)Full Summer
If you have additional children, please submit a second registration form.
2. Parents' Information
Phone Number*

Area Code Phone Number
Parent 1 Name*
First Name Last Name
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
E-mail*
Primary email
Parent 2 Name
First Name Last Name
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
E-mail
Primary email
How did you hear about us?
3. Emergency Information
Emergency Contact*
First Name Last Name
Phone Number*

Area Code Phone Number
Relationship*
Pediatrician
First Name Last Name
Phone Number

Area Code Phone Number
Insurance
4. Payment Agreement
A $99 Non-Refundable Deposit will be charged, per camper, at registration. The other payments will be charged before camp starts.

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Total Amount Paid for Camp 2024 Deposit ($99 for one camper, $198 for 2, $297 for 3)*

$99$198$297
Total

$0.00
5. Agreement
I am signing up my child for camp. I accept full financial responsibility for on time payment.
I give my child permission to attend all trips and receive medical care in the case of emergency.
I give permission to photograph and videotape my children to use for promotion (without their names).
Comments & Allergy Information
Should be Empty:

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1. Child(ren)'s Information