2019 Winter Camp 1/2 Day Registration
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Relationship to Student*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Please provide the name and phone number of an Emergency Contact if we are unable to reach you
Students entered below will be added to your family's account
Please supply an emergency contact name and number for us to reach you during Winter Camp.*
Please list any Allergies or Medical Conditions that your child has .*
Registration requires a deposit of $75.00/child (balance due by Feb 10). Supply credit card details below. Select YES to charge your card the full balance, select NO to charge deposit only.*
If you have a COUPON CODE, please enter it here.
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*