Summer Camp Application

I understand that camp will begin on Monday, June 27, 2022 and end on Friday, August 12, 2022: *

I understand the cost of camp includes trips, activities, breakfast, lunch, (2) camp shirts, and a book bag: *

Also, I understand there are no additional charges & parents are responsible for spending money: *

I understand the camp will provide the opportunity for youth to participate in activities, trips, and swimming weekly: *

I understand the camp calendar will be given to all families on the first day of camp: *

I understand that camp begins at 8:00am ? *

I understand youth are suppose to be picked up from the program by 5:00 pm: *YesNo

I understand breakfast & lunch will be provided or youth can bring their own: *YesNo

Are there any allergies: *

I understand youth must bring their own snack or can purchase snack from the camp? *

I/We understand that camper will be provided camp shirt and bag on their first day of camp: *

I understand that youth must wear his/her camp shirt and sneakers daily: *

I understand to put camper’s name on all belongings sent to camp each day: *

I understand that all youth will participate in two hours of academic curriculum: *

What are your child strengths & weakness in regards to his/her academics:?

I understand the camp reserves the right to dismiss from camp any student who demonstrates any disruptive or unsafe behavior with no refund:Select *

I understand the camp calendar is subject to change due to weather, a trip will be reciprocated." *

I understand that a $100 deposit is required to guarantee your youth a slot in the camp: *This will be applied the cost of shirts, bags, and the overall cost.

Do you have "subsidy" or "private pay" method: *CCISPrivate Pay (Cash/Debit)

Which payment arrangement do you prefer: *

I understand there will be "NO REFUNDS" for any summer camp deposits/payments: *

Youth Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date Of Birth *

Mother’s Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mobile Phone

Email Address

Place of Employment

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Father’s Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mobile Phone

Email Address

Place of Employment

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Emergency Contact Name *

Phone *

Emergency Contact Name

Phone

Emergency Contact Name

Phone

Name Of Child’s Physician

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Special Disabilities (If Any)

Allergies(Including Medication Reaction)

Medical or Dietary Information

Additional Information On Special NeedsOf Youth:

Health Insurance or Medical Assistance:

Youth May Walk/Trips

Youth May Go Swimming/Wadding

Youth Can Be Transported

Youth Name

Grade

Youth Room #

School Youth Attends:

Will youth be picked up/walk home: