ZAP Summer Camp Registration

Please select camp weeks you'd like to register for:*

Select All
Week 1: July 6-10 – Friendship Fest (FULL)
Week 2: July 13-17 – Discovery Lab (FULL)
Week 3: July 20-24 – Art Explosion (FULL)
Week 4: July 27-31 – Nature Quest (FULL for younger group)
Week 5: Aug 4-7 – Sports Extravaganza
Week 6: Aug 10-14 – Carnival Chaos
Week 7: Aug 17-21 – Wild Water Week (FULL)
Week 8: Aug 24-18 – ZAP Stars (FULL)

Child's Information

Child's Name*

First Last

Child's Address*

Street Address City Postal Code

Child's Birthdate*

Child’s Birthdate

Gender

Mother /Guardian Contact Information

Mother / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Mother / Guardian Email

Email

Father/Guardian 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 applicable)*

*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*

Street Address City Postal Code

List of People allowed to Pick up your child

we won’t release child to anyone who is not listed on registration form.

Who will pick up child within 30 minutes if they are ill. (Mother, Father, or Emergency Contact)*

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

Yes
No

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)

Dietary restrictions (please list)

Does your child have any Developmental/Learning Delays (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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