Student's Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Primary Contact *

First Name

Last Name

Primary Contact Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

If different than Primary Contact

First Name

Last Name

Emergency Contact Phone

If different than Primary Contact

(###)

###

####

Lunch Option *

Student will eat the camp provided lunch

Student will pack a lunch

Register: *

Week 1 (June 9 - June 13)

Week 2 (June 16 - June 20)

Week 3 (June 23 - June 27)

Week 4 (June 30 - July 3) *No camp on Friday, July 4

Week 5 (July 7 - July 11)

Week 6 (July 14 - July 18)

Camp Hours *

9:00am - 3:00pm

Extended Hours: 8:00am - 4:30pm (+$25/week)

I would like to pay: *

Weekly

All at once