Name of student attending:
(required)
Student's age:
(required)
Date of Birth :
(required)
Grade student will be entering in the fall of 2015:
(required)
Name of parent/guardian:
(required)
Cell Phone Number:
(required)
Home Phone Number:
(required)
Work Phone Number:
(required)
Street Address:
(required)
City and zip:
(required)
Parent's email address:
Parent's home address if diffrent from that of child attending :
City and Zip:

The parent who's contact information is listed above, will be considered the primary contact in the case of an emergency. The contact below will be called only if we are not able to get in touch with the primary contact.  

Emergency contact name other than yourself:
(required)
Emergency contact phone number:
(required)
List any physical limitations :
(required)
Any known allergies or other medical conditions:
(required)
Any medications :
Primary care physician:
Session Attending, please choose only one:
(required)

Camp Hours: 8:00 a.m. until 3:00 p.m. Daily

Students can not be dropped off before 7:30 a.m. They must also be picked up promptly at 3:00 p.m.

New Location, To Be Determined.