summer camp 2016 registration form -...

500 S.E. 18 th Court, Fort Lauderdale, FL 33316 500 S.E. 18 th Court, Fort Lauderdale, FL 33316 954-440-2483 Summer Camp 2016 Registration Form Please forward forms via email to [email protected] Camper’s Name: ________________________________________________________________ DOB: _______________ Parent(s)/Caregiver(s) Name___________________________________________________________________________ Parent/Caregiver Contact Information: __________________________________________________________________ Parent/Caregiver Email address: _______________________________________________________________________ Emergency Contact Name and Phone #: _________________________________________________________________ School and Grade: ___________________________________________________________________________________ Home Address, City, State and Zip: _____________________________________________________________________ Individuals authorized to pick up child: __________________________________________________________________ Please CIRCLE which camp dates your child will attend: SESSION 1: Week 1: June 13-17 Week 2: June 20-24 SESSION 2: Week 3: June 27 to July 1 Week 4: July 5-8 SESSION 3: Week 5: July 11-15 Week 6: July 18-22 Maximum of 12 campers! Does your child have any dietary restrictions (allergies, kosher, gluten free)? If so, please list: ______________________ __________________________________________________________________________________________________ Please list any goals/expectations you may have for your child’s camp experience: _______________________________ __________________________________________________________________________________________________ What activities does your child enjoy doing? ______________________________________________________________ __________________________________________________________________________________________________ Please tell us anything that would be important for us to know about your child: ________________________________ __________________________________________________________________________________________________ Signature: ________________________________________________________________ Date: _____________________ Print Name: _______________________________________________________________ Relation to child: ____________

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Page 1: Summer Camp 2016 Registration Form - storage.googleapis.comstorage.googleapis.com/wzukusers/user-15584247... · Summer Camp 2016 Registration Form-Page 2 Camper’s Name: _____ Fees

500S.E.18thCourt,FortLauderdale,FL33316

500S.E.18thCourt,FortLauderdale,FL33316954-440-2483

SummerCamp2016RegistrationForm

[email protected]

Camper’sName:________________________________________________________________DOB:_______________Parent(s)/Caregiver(s)Name___________________________________________________________________________Parent/CaregiverContactInformation:__________________________________________________________________Parent/CaregiverEmailaddress:_______________________________________________________________________EmergencyContactNameandPhone#:_________________________________________________________________SchoolandGrade:___________________________________________________________________________________HomeAddress,City,StateandZip:_____________________________________________________________________Individualsauthorizedtopickupchild:__________________________________________________________________

PleaseCIRCLEwhichcampdatesyourchildwillattend:

SESSION1: Week1:June13-17 Week2:June20-24

SESSION2: Week3:June27toJuly1 Week4:July5-8

SESSION3: Week5:July11-15 Week6:July18-22

Maximumof12campers!

Doesyourchildhaveanydietaryrestrictions(allergies,kosher,glutenfree)?Ifso,pleaselist:________________________________________________________________________________________________________________________Pleaselistanygoals/expectationsyoumayhaveforyourchild’scampexperience:_________________________________________________________________________________________________________________________________Whatactivitiesdoesyourchildenjoydoing?________________________________________________________________________________________________________________________________________________________________Pleasetellusanythingthatwouldbeimportantforustoknowaboutyourchild:__________________________________________________________________________________________________________________________________

Signature:________________________________________________________________ Date:_____________________PrintName:_______________________________________________________________ Relationtochild:____________

Page 2: Summer Camp 2016 Registration Form - storage.googleapis.comstorage.googleapis.com/wzukusers/user-15584247... · Summer Camp 2016 Registration Form-Page 2 Camper’s Name: _____ Fees

500S.E.18thCourt,FortLauderdale,FL33316

500S.E.18thCourt,FortLauderdale,FL33316954-440-2483

SummerCamp2016RegistrationForm-Page2Camper’sName:________________________________________________FeesandPaymentOptionsforCamp:$50RegistrationFee-DueattimeofSign-uporbydateofIntakeConsultation.$225perweek*Allcampfeesareduebyatleastfourteen(14)dayspriortothefirstdateofcamp*Inordertoprovideadequatestaffingandpreparationsforthecamp,pleasenotethatcancellationlessthanseven(7)dayspriortocampand/orno-showdayswillnotberefunded.Pleaseinitialone:_____Iwillpay$_____bycashorcheck(onorbefore14dayspriortoyourchild’sfirstdayofcamp)_____Iwillpay$_____bycreditcard(yourcreditcardwillbecharged14dayspriortoyourchild’sfirstdayofcamp)10%Siblingandmulti-weekdiscounts(ifregisteredformorethan2weeks)*Registrationwillbechargedattimeofsignuporinitialconsultation.Belowismycreditcardinformation.PLEASESIGN-Signature:_________________________________________ Date___/___/___

NameonCard:___________________________________________________________________IauthorizeEvolveLearningCommunitytochargemycreditcardasfollows:PleaseCircle: $50RegistrationFee Amountbasedoncampattending$ PerWeekTypeofCard: Visa MasterCard ExpirationDate:____________________CreditCardNumber:______-______-______-______,CVVNumber________3-digitnumberonthe

backofthecreditcardCardHolder’sBillingAddressforCreditCardStatements:________________________________________________________________________________Street City State Zipcode

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