Form

Heritage Camp Registration
To Register your Child and Pay Online, Click Here to use a Separate Form.
Part 1 - Parent or Guardian Information
Date of Registration
/ Month / Day Year
Parent or Guardian Full Name*
Prefix First Name Last Name Suffix
Parent's E-mail*

Address*

Contact Number*
- Area Code Phone Number
Alternate Phone Number (Job, House, Cell Phone)*
- Area Code Phone Number
Emergency Contact Name
First Name Last Name
Emergency Contact
- Area Code Phone Number
Relationship to Child
Part 2 - Child Information
Full Name*
First Name Middle Name Last Name Suffix
Male or Female*

Male Female
Birth Date*
Month Day Year
Age
Grade Child will be Enrolling in September*
Special Needs, Allergies, or Information:
Additional Child Registration (2nd Child)
Full Name
First Name Middle Name Last Name Suffix
Male or Female

Male Female
Birth Date
Month Day Year
Age
Grade Child will be Enrolling in September
Special Needs, Allergies, or Information:
Part 3 - Session Registration
Registration Fee ($150) is per child, per week. Extended Day Care ($60) is per Family.
Week Sessions:*

Session 1: June 25th-June 29th ($150.00) Session 2: July 9th-July 13th ($150.00) Session 3: July 23rd - July 27th ($150.00)
Registration for # of Children:
Extended Day Care Selection (Optional):

Session 1: Extended Day Care ($60.00) Session 2: Extended Day Care ($60.00) Session 3: Extended Day Care ($60.00)
Payment Selection:
Mail Check or Money Orders to:

Heritage Education Group
ATTN: Heritage Camp
112 Harvard Ave. #124
Claremont, CA 91711
Should be Empty:

Heritage Camp Registration