Waitlist Summer Camp 2017

Creative Summer Camps for Kids Waitlist
Camper's Information
Camper's Name*

First NameLast Name
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Camps for 6-10 Year Olds
Please select camp(s)

Week 5: July 10-14 - Sewing CampWeek 6: July 17-July 21 - CookingWeek 7: July 24-28 - Enchanted Hikes & FairiesOther
Parent or Legal Guardian Information
Parent/Legal Guardian*

First NameLast Name
Relation*
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail*
Parent/Legal Guardian 2

First NameLast Name
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
E-mail
Emergency Contact Info
Emergency Contact Name (if parent or guardian is not available)*

First NameLast Name
Emergency Number*

Area CodePhone Number
Emergency Number #2*

Area CodePhone Number
Health Information
Last Tetanus Shot

MonthDayYear
Any physical or other condition that would require special attention or medication while at camp?*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?
Camper Photo Release
I agree that photos of my child can be taken on used on for camp social media purposes*

YesNo
I would like to receive your e-newsletter. Please add me to your mailing list.*

YesNo
Release of Liability, Behavioral Expectations, and Refund Policy

I certify that my child has my permission to attend camp and participate in all activites. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I understand that the above named camper will only be released to the names listed above, an update may be done at registration.

If Creative Roots cancels a program at any time, participants will receive a full refund. Creative Roots is unable to offer any other type of refund, but participants may be eligible for a credit towards other programs at Creative Roots. Contact Monique for approval.

Children are expected to follow the expectations of camp instructors in order to maintain the safety and wellbeing of all campers. Parents of children whose behavioral challenges require more supervision than we are able to offer during camp, will be asked to meet with Monique to develop a plan. If the plan does not ensure campers' safety and wellbeing, camp attendance may be limited.

By submitting this form and entering your initials below, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18, and have read and agree to the camp policies as listed above.

My Products

Summer Camps $325.00

Quantity
Item subtotal:$0.00

Sibling Discount$300.00

Quantity
Item subtotal:$0.00

3-Day Summer Camp (Week 4)$225.00

Quantity

June 15, 2017$75.00

Quantity
Item subtotal:$0.00

June 16, 2018$75.00

Quantity
Item subtotal:$0.00

Before Care - 1 hr$10.00

Quantity

After Care - 1 hr$10.00

Quantity

After Care - 1.5 hr$15.00

Quantity

Enter coupon

Total $0.00

Payment Information

Please sign here to confirm that you have read and agree to the refund and release of liability policies.
Signature*

Clear
Should be Empty:

Creative Summer Camps for Kids Waitlist

Camper's Information

Parent or Legal Guardian Information

Emergency Contact Info

Health Information

Camper Photo Release

Payment Information