Summer Camp 2019 - Application Form/ Dates & Rates

Camper's Information
Child's Last Name
Child's First Name
Child's Date of Birth
Home Phone
Address
City
State
Zip
Parent Information
Mother's Name

Cell Phone
Email
Mothers Work Phone
Business Address
 
Father's Name
Cell Phone
Email
Work Phone
Business Address
Siblings (please enter name and age for each sibling)
Emergency Contact
Emergency Contact Name
Home Phone
Full Home Address
Work Phone
Relationship to Child
Mobile Phone
Pediatrician
 Phone
Allergies
Additional Information
Language spoken at home
Language spoken by child
Is There Anything Special That We Should Know About Your Child?
Comments
Tuition
Ages: 18 month - 5 years
Hours: 9:00 AM - 2:00 PM (Aftercare is available $20 per session from 2-4pm and 4-6pm, Mon -Thurs.) 
Dates of Summer Camp
July 1-5 July 8-12 July 15-19 July 22-26 July 29-August 2
Tuition
$400 • per week $20 • per session - aftercare