Registration
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Storybook Camp Event 2019 Wells - July 8th-12th
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Relationship to Student
*
Both Parents
Father
Grandparent
Guardian
Mother
Other
Parent
Student
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Birth Date:
*
(format=mm/dd/yyyy)
Any Allergies or Medical Conditions we should be aware of?:
Questions/Options:
Please supply an emergency contact name and number for us to reach you during Summer Camp.
*
Please list any Allergies or Medical Conditions that your child has .
*
If you have a COUPON CODE, please enter it here.
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number:
Visa
Mastercard
Amex
Discover
Name as it appears on card:
Nickname:
Card Expiration Month:
01
02
03
04
05
06
07
08
09
10
11
12
Exp Year:
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
Address Line 1:
Address Line 2:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip:
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