Summer Enrichment Camp Application

Southern Angels Exceptional Ed Consulting

Summer Enrichment Camp 4 All

4243 Lebanon Pike, Suite C, Hermitage, TN 37076-2170 info@southernangelscomprehensive.com 615-600-5107

***Please complete a form for each child***
Full Name
Date of Birth MMDDYYYY

MonthDayYear
Grade in Summer 2026
Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
My Child will partake in Summer Enrichment Camp from June 1-30, 2026 (8:00 a.m.- 3:00 p.m. for $180.00 for the 1st Child and $170.00 for the 2nd Child)
I would like Before Care for June 1-30, 2026 (7:00 a.m.- 8:00 a.m. for $30.00)
I would like After Care for June 1-30, 2026 (3:00 p.m.- 4:00 p.m. for $30.00)
I would like both Before & After Care for June 1-30, 2026 $55.00 per week
Medical & Emergency Information
Allergies Medical Conditions
Medications Required During Camp
Doctor's Name
Emergency Contact (Other than Parent/Guardian):
Name
Phone Number
Format: (000) 000-0000.
Relationship
Does your child receive special education services or accommodations?
If yes please type yes and upload; if no, please type N/A.
File Upload

Cancelof
Does your child have any behavior issues?
If yes please describe all behaviors and triggers; if no, please type N/A
Is there anything else we should know to best support your child
Family Agreements
Signature of Parent Guardian
Date

MonthDayYear
Date
Submission Instructions Please return this completed form via Jot. If you have any questions feel feel free to: Email: info@southernangelscomprehensive.com Or drop by the office at: 4243 Lebanon Pike, Suite C, Hermitage, TN 37076-2170
Summer Enrichment Camp options:
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Summer Break Child 1
June 1-30, 2026 from 8:00-3:00 p.m.

$180.00 Quantity



Summer Break Child 2
June 1-30 2026 from 8:00-3:00 p.m.

$170.00 Quantity



Before Care: June 1-30, 2026
Before 7:00AM-8:00 AM

$30.00 Quantity



After Care: June 1-30, 2026
After Care 3:00PM-4:00PM

$30.00 Quantity



Before & After Care: June 1-30, 2026
Before & After Care

$55.00 Quantity



Summer Enrichment Application Fee
Per Child

$7.00 Quantity



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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Summer Enrichment Camp options:

Payment Methods