Academic Camps Registration Form

(Please print this page and complete one sheet per child)

(Registration Form Due 1 week before camp)

Child's Name ____________________________ Birthdate_____________________

Weekday School and grade your child will attend this Fall _____________________

Child's Address: _______________________________________________________

Parent's Names __________________________________

Please circle whom to contact first and which number is best during the day?

Home Phone _______________ Work Phone ____________________

Mom Cell __________________Dad Cell _______________________

In Case of Emergency (other than parents) ______________________________

Relationship to child: _________________ phone _________________________

Child's Dr. ________________________phone _________________________

Allergies (Please specify food, animals (I have 3 cats) & insect bites)

_______________________________________

Medication needed in case of an emergency: (inhaler, epi-pen) Will child have with them? Y or N

What email address is the best to receive all camp communications? (please print clearly)

Primary Email Address _____________________________________________________

Secondary Email Address ___________________________________________________

People authorized to pick up my child are:

__________________________ relationship _______________ # _____________

I hereby give permission for my child to participate fully in camp - including but not limited to walking field trips to the park & outdoor games, if appropriate.

Parent/Guardian Signature:_____________________________

Date: ______________

~ Registration forms and a non-refundable $200 deposit: Due upon registration

~Remaining balance is due on the first day of camp.

~Checks made payable to: Stephanie Scalise