Download - 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

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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:____________

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