Name Parent/Guardian 1 *

First Name

Last Name

Cell Phone: Parent/Guardian 1 *

(###)

###

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Work Phone: Parent/Guardian 1 *

(###)

###

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Name: Parent/Guardian 2

First Name

Last Name

Cell Phone: Parent/Guardian 2

(###)

###

####

Work Phone: Parent/Guardian 2

(###)

###

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Additional Caregiver

If applicable - Nanny, grandparent, etc.

First Name

Last Name

Additional Caregiver Phone

(###)

###

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Child's Name *

First Name

Last Name

Child's Sex *

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone

(###)

###

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Does Child Receive Special Services *

No

Speech

OT

PT

Other

Summer Camp Program (please select) *

Summer Camp runs June 24th- August 1st from 9am - 11:15/30am. You may choose 2 days ($125wk) a week or 4 days ($250wk) and may attend any 1 - 6 weeks. Please select from the below:

Week 1: June 24th - June 27th (2 days)

Week 1: June 24th - June 27th (4 days)

Week 2: July 1st - 3rd (2 days)

Week 2: July 1st - 3rd (3 days- $185)

Week 3: July 8th - 11th (2 days)

Week 3: July 8th - 11th (4 days)

Week 4: July 15th - 18th (2 days)

Week 4: July 15th - 18th (4 days)

Week 5: July 22nd - 25th (2 days)

Week 5: July 22nd - 25th (4 days)

Week 6: July 29th -August 1st (2 days)

Week 6: July 29th -August 1st (4 days)

2 Day Program Only

If your child will be attending the 2 day program do you prefer a Monday/Wednesday or Tuesday/Thursday Program. We will do our best to accommodate all requests, priority will be given to early applicants.

Monday/Wednesday

Tuesday/Thursday

Child 2 Name

First Name

Last Name

Child 2 Sex

Male

Female

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 2 Home Phone

(###)

###

####

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other

Program (please select)

Summer Camp runs June 24th- August 1st from 9am - 11:15/30am. You may choose 2 days ($125wk) or 4 days ($250wk) and may attend any 1 - 6 weeks. Please select from the below:

Week 1: 2 days

Week 1: 4 days

Week 2: 2 days

Week 2: 3 days

Week 3: 2 days

Week 3: 4 days

Week 4: 2 days

Week 4: 4 days

Week 5: 2 days

Week 5: 4 days

Week 6: 2 days

Week 6: 4 days