Summer Camp 2017 Registration

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FAIRY TALE CAMP | AGES 4-6 AUGUST 7-11
$140/members, $165 visitors
 
Enter your 4- or 5-digit member #:
Total Cost
 
How did you hear about our camps?
         

Child
Name
Child's Birth Date
//
Gender
  
Child's Nickname

Parent/Guardian
Name
Relation
Home Phone
Cellular Phone
Work Phone
Email
Address
City, State Zip
,

Addit'l Parent/Guardian
Name
Relation
Home Phone
Cellular Phone
Work Phone
Email
Address
City, State Zip
,

Alternate Emergency Contact
Name
Relation
Home Phone
Cellular Phone
Work Phone

Adults who are authorized to pick up your child from camp in addition to guardian(s)
Name
Relation
Phone

Name
Relation
Phone

Name
Relation
Phone


Special Information
Does your child have any allergies and/or serious medical conditions? Please describe:
Is your child taking medication that will continue through his/her camp? Please describe:
Please feel free to use this space if there is anything else you would like to share about your child:

Payment Please let us know how you'd like to pay.

Credit Card #
Security Code
Expiration Date (MMYY please)
Name & address for Credit Card:
First Name
Last Name
Address
City, State Zip