Summer Camp Enrollment Form

Summer Camp Registration
CHILD INFORMATION:
Child's Name (1)

First NameLast NameBirthday
Allergies:
Child's Name (2)

First NameLast NameBirthday
Allergies:
Child's Name (3)

First NameLast NameBirthday
Allergies:
Child's Name (4)

First NameLast NameBirthday
Allergies:
Select a Camp Selection
*For Drop-in Day please list the dates you'd like to attend
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Parent/Guardian Name * Additional

First NameLast Name
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Emergency Contact Info

NameRelationship to childPhone Number
MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Medical Concerns
Sunscreen & Outdoor Activity Permission
I understand that camp activities may take place outdoors in varying weather conditions. I give permission for my child to participate in outdoor activities including walking, games, water play, nature exploration, and park activities. I give permission for staff to assist my child with applying sunscreen provided by:
Photo Release
Pick-Up & Drop-Off Authorization:
Authorized Person(s)

NameRelationship to childPhone Number
Authorized Person(s)

NameRelationship to childPhone Number
Special Drop-Off & Pick-Up instructions

Full Week Enrichment Camp

*Chose this selection for any of the full week camps

$200.00 Quantity
Item subtotal:

Drop-In Day For Enrichment Camps

*For Any 1 Day for any of the Camps

$60.00 QuantityDate

Registration Fee

(Uplift Co-Op Summer membership Fee)

$10.00 Quantity

Enter coupon

Total

Credit Card

Apple Pay

Google Pay

Summer Camp Registration