Registration

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* Indicates required field

Parent/Guardian Name *

First

Last

Email *

Child's Name *

Child's Age *

Grade Completed (Select One) *

Please mark if your child is male or female *

Male Female

Parent/Guardian(s) Name and Address (Please include first name, last name, street address, city, state, and zip) *

Home Phone *

Work Phone *

Cell Phone *

Secondary Email Address *

Primary Physician Name and Phone Number *

Any allergies, medications, or special conditions? If yes, please specify: *

Does your child know how to swim? *

Yes-Beginner Yes-Advanced No

Name and phone number of emergency contact in the event a parent or guardian cannot be reached: *

Emergency Contact's Relationship to the Child: *

Name and phone number of person who has permission to pick up your child: *

Name and phone number of second person who has permission to pick up your child: *

Is there anything else we need to know about your child? *

Please mark your chosen payment plan *

7 Week Session 8 am-3pm - 1 payment of $1195 due 5/31 7 Week Session 8 am-3pm - 2 payments of $615 due 5/31 and 6/24 7 Week Extended Session 7:30am-5:30pm - 1 payment of $1330 due 5/31 7 Week Extended Session 7:30am-5:30pm - 2 payments of $685 due 5/31 and 6/24 Weekly Session 8am-3pm (must have at least one week advance notice) - $179 Weekly Session Extended 7:30am-5:30pm (must have at least one week advance notice) - $199

Session Dates: Please select the dates your child will be attending camp. *

Please read the following information carefully:

No tuition credits or makeup days will be given. Tuition remains the same whether or not a child attends. A child may be withdrawn and tuition will be refunded on a pro-rated basis (less the Registration Fee) by giving written notice to the Camp Director at least two weeks in advance of withdrawal. If a student attends any portion of a weekly session, the child is charged for the entire session.

Please type the name of your student here if he/she has permission to attend any field trips associated with Camp Eagle. *

Please type the name of your student here if Camp Eagle has permission to use photographs, videos, written extractions, and voice recordings of your child for the purpose of illustrations and publications. *

Please type your name here if you authorize any Camp Eagle staff member to have your student examined by a qualified physician or dentist, and in the event of injury to administer any emergency care he/she deems necessary to ensure proper treatment. Every effort will be made to contact the parent or guardian to explain the nature of the problem prior to any involved treatment. *

I hereby agree to relieve Camp Eagle and ACA and/or its officers of any liability for injury or accident occurring on the premises, or while on a field trip or athletic competition trip. I give my permission for my child to make field trips accompanied by camp personnel, as part of the Camp's activities. PLEASE TYPE PARENT/GUARDIAN NAME HERE. *

Date *

register Below

Please read the following information carefully:

A $50 Registration fee (per camper) is due to complete registration.