Summer Camp Registration Form

Summer Camp Registration
Camper Information
Camper's Name *

First Name Last Name
Birth Date *

Month Day Year
Grade Completed *
School *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Please check the appropriate week(s) your child will attend camp. *

June 1-5 June 8-12 June 15-19 June 22-26 June 29 - July 3 July 6-10 July 13-17 July 20-24
Parent/Guardian Information
Parent 1 Name *

First Name Last Name
Parent 1 Home Number *

Area Code Phone Number
Parent 1 Cell Number *

Area Code Phone Number
Parent 1 Work Number *

Area Code Phone Number
Parent 1 E-mail *
example@example.com
Parent 2 Name

First Name Last Name
Parent 2 Home Number

Area Code Phone Number
Parent 2 Work Number

Area Code Phone Number
Parent 2 Cell Number

Area Code Phone Number
Parent 2 E-mail
The following persons have permission to pick up your child from Gorman Christian Academy. (Please include name, relationship, and phone number.) *
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe. *
Physician's Name *

First Name Last Name
Physician's Phone Number *

Area Code Phone Number
Health Insurance Company *
Policy Number *
Camp Dates

Please select each date that your child will be attending camp.
New scheduling/cancellation policy – In order to ensure that we have a safe number of students for our campus and field trip locations, we will need accurate head counts at least two weeks in advance. Please select each date that your child will be attending camp. If your schedule changes, we will need to be notified at least two weeks in advance of that date, or you will incur a $25 late cancellation fee. Thank you for helping us keep our campers safe and healthy!
Week 1 - Ancient Egypt

Monday June 1 Tuesday June 2 Wednesday June 3 Thursday June 4 Friday June 5 All of the above
Week 2- Outer Space

Monday June 8 Tuesday June 9 Wednesday June 10 Thursday June 11 Friday June 12 All of the above
Week 3 - Dinosaurs

Monday June 15 Tuesday June 16 Wednesday June 17 Thursday June 18 Friday June 19 All of the above
Week 4 - 50's Diner

Monday June 22 Tuesday June 23 Wednesday June 24 Thursday June 25 Friday June 26 All of the above
Week 5 - Revolutionary War

Monday June 29 Tuesday June 30 Wednesday July 1 Thursday July 2 Friday July 3 All of the above
Week 6 - Wild West

Monday July 6 Tuesday July 7 Wednesday July 8 Thursday July 9 Friday July 10 All of the above
Week 7 - Olympics in Ancient Greece

Monday July 13 Tuesday July 14 Wednesday July 15 Thursday July 16 Friday July 17 All of the above
Week 8 - The Future

Monday July 20 Tuesday July 21 Wednesday July 22 Thursday July 23 Friday July 24 All of the above
Informed Consent and Acknowledgement

We are financially responsible for the weeks we reserve and will pay on Monday of each week or the first day attended. If our child needs medical services, staff members of Gorman Christian Academy have our consent to take our child to a properly licensed practicing physician or to call EMS. We release Gorman Christian Academy and its staff from any and all liability in such situations.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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Summer Camp Registration

Camp Dates