Summer Camp Registration

Please indicate which camp week(s) you are registering for:*

Please note that camp hours are from 7:00am-5:30pm, Monday - Friday and for kids ages 5-12 years.

Select All
Week 1: July 4-7 - Art Adventures
Week 2: July 10-14 - Princesses & Pirates
Week 3: July 17-21 - Going for Gold!
Week 4: July 24-28 - Nature Adventures
Week 5: July 31 - Aug 4 - Splish Splash!
Week 6: Aug 8-11 - Movin' & Groovin'
Week 7: Aug 14-18 - Carnival Craze
Week 8: Aug 21-25 - Camp Rewind

Child's Information

Child's Name*

First Last

Child's Address*

Street Address City Postal Code

Child's Birthdate*

Child's Birthdate

*

Grade

*

Gender

Parent / Guardian #1 Contact Information

Mother / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Mother / Guardian Email

Email

Parent/ Guardian #2 Contact Information

Father / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Father / Guardian Email*

Email

Parent/Guardian with legal custody*

*If there is a custody order please include a copy with your registration

Emergency Contact Information

Emergency Contact (Cannot be Mother or Father, must have a local address)

Emergency Contact Name*

Name Cell# Work#

Emergency Contact Address*

Emergency Contact Address

List of People allowed to Pick up your child

Are there any immediate family members that should be denied phone calls with your child?

Additional people who may pick up your child:

Who will pick up child within 30 minutes if they are ill. (Parent/ Guardian or Emergency Contact)*

Medication Required (epi pen, puffer, etc.)?*

Yes
No

Medication Required Type*

Medication Required Type

Relevant Health information (Medical Condition (s))?*

Yes
No

List Medical Condition(s):*

List Medical Condition(s):

Does your child have any pre-existing conditions that may present as influenza like symptoms? Ex: Allergies, chronic cough, etc*

Yes
No

List pre-existing Condition(s):*

List pre-existing Condition(s):

Is Your Child Immunized?*

Yes
No

Allergies?*

Yes
No

Allergies please list*

Does your child have any dietary restrictions? Please list.

Does your child have any Developmental/Learning (ie. Diagnosed or suspected ADD/ADHD/ODD/Autism/Delays)?*

Yes
No

If yes, please indicate details:*

Does your child require any additional assistance?*

Yes
No

If yes, please indicate details:*

Please list any other relevant information:

Cultural Background:

I agree:*

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Name

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Please complete the following information to submit your Summer Camp registration.

Summer Camp 2023 Public Registration

Child's Information

Parent / Guardian #1 Contact Information

Parent/ Guardian #2 Contact Information

Emergency Contact Information