Registration Form - Summer  Camp 5779/2019

Application forms must be submitted with a non-refundable registration fee of $50.  
Note: Please use a separate form for each child. 

Child/Parent Information
Child's First Name  
Child's Last Name
City,State, Zip:      
Date of Birth: //
Mother Name:
Mother Cell:
Mother Email:
Father Name:
Father Cell:
Father Email:
Emergency Contact, Name and Number  
Pediatrician, Name and Number  
I am signing up for 3:00-4:00 After Care: 
For Napping Toddlers only: Will your child be napping in camp or picked up at 1:00?
Napping Child:   
Non-refundable Registration Fee: $50:
Please enter your card information below
Card Type:
Card Number:
Exp. Date: