Name Parent/Guardian 1 *

First Name

Last Name

Cell Phone: Parent/Guardian 1 *

(###)

###

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Work Phone: Parent/Guardian 1 *

(###)

###

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Name: Parent/Guardian 2

First Name

Last Name

Cell Phone: Parent/Guardian 2

(###)

###

####

Work Phone: Parent/Guardian 2

(###)

###

####

Additional Caregiver Name

If applicable- nanny, grandparent, etc.

First Name

Last Name

Additional Caregiver Phone

(###)

###

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Child's Name *

First Name

Last Name

Child's Sex *

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone

(###)

###

####

Does Child Receive Special Services *

No

Speech

OT

PT

Other

Summer Camp Program (please select) *

Summer Camp runs June 24th- August 1st from 9am - 11:45am. You may attend any 1 - 6 week 4 day program ($250 week). Please select from the below:

Week 1: June 24th - June 27th (4 days)

Week 2: July 1st -3rd (3 days- $185)

Week 3: July 8th - 11th (4 days)

Week 4: July 15th - 18th (4 days)

Week 5: July 22nd - 25th (4 days)

Week 6: July 29th - August 1st (4 days)

Child 2 Name

First Name

Last Name

Child 2 Sex

Male

Female

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 2 Home Phone

(###)

###

####

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other

Program (please select)

Summer Camp runs June 24th- August 1st from 9am - 11:45am. You may attend any 1 - 6 week 4 day program ($250 week). Please select from the below:

Week 1: June 24th - June 27th (4 days)

Week 2: July 1st - 3rd (3 days- $185)

Week 3: July 8th - 11th (4 days)

Week 4: July 15th -18th (4 days)

Week 5: July 22nd - 25th (4 days)

Week 6: July 29th - August 1st (4 days)