Clone of April 6-10 Spring Break Day Camp at Phase

1
Child #1 Full Name* This field is required.
First Name
Last Name
2
Child # 1 Date of Birth* This field is required.
Date
Month
Day
Year
3
Current Grade for Child #1* This field is required.In which class is your child currently enrolled?
Please Select
Please Select
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
4
Child #2 Full Name
First Name
Last Name
5
Child #2 Date of Birth
Date
Month
Day
Year
6
Current Grade for Child #2In which class is your child currently enrolled?
Please Select
Please Select
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
7
Are there any special accommodations that may be required to most effectively meet your child's needs while at Spring Break Day Camp?Please indicate which child by name.
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Large
Normal
Small
Ok
Ok
8
Does your child take medications regularly and/or pre-existing illness or health concerns?* This field is required.Please indicate which child by name.
None
Other
9
Does your child have allergies or food restrictions?* This field is required.Please indicate which child by name.
None
Other
10
Name (Parent/Guardian #1)* This field is required.
First Name
Last Name
11
Cell Phone Number* This field is required.
Area Code
Phone Number
12
Email Address* This field is required.
13
Work Phone NumberIf applicable
Area Code
Phone Number
14
Name (Parent/Guardian #2)* This field is required.
First Name
Last Name
15
Cell Phone Number* This field is required.
Area Code
Phone Number
16
Email Address* This field is required.
17
Work Phone NumberIf applicable
Area Code
Phone Number
18
Emergency Contact Name* This field is required.
First Name
Last Name
19
Emergency Contact Cell Phone Number* This field is required.
Area Code
Phone Number
20
Emergency Contact Work Phone NumberIf applicable
Area Code
Phone Number
21
Emergency Contact's Relationship to the Child* This field is required.
22
Please list the names of any additional authorized pick up people.
23
Any additional information?
24
My Products
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My Bag
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$20
Quantity:1
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
CC Processing Fee (3.5%)USD
SubtotalUSD
Total costUSD
Monday, April 6
$50.00Edit
Back
1
1
2
3
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5
6
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9
10
Quantity
Subtotal: $0.00
Tuesday, April 7
$50.00Edit
Back
1
1
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3
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6
7
8
9
10
Quantity
Wednesday, April 8
$50.00Edit
Back
1
1
2
3
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7
8
9
10
Quantity
Thursday, April 9
$50.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Friday, April 10
$50.00Edit
Back
1
1
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5
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7
8
9
10
Quantity
Total cost $0.00
First Name
Last Name
25
Should be Empty: