Preschool Summer Camp Enrollment Form


Parent Information

Parent 1
Last Name
First Name
Street Address
City
State
Zip
Home Phone
Cell Phone
Email
ADD ANOTHER PARENT.
Yes
Parent 2
Last Name
First Name
Street Address (if different from Parent 1)
City
State
Zip
Home Phone
Cell Phone
Email
Emergency Contact(s) (other than parents)
Name
Phone
Relationship (to children)
Name
Phone
Relationship (to children)

Child Information

Child 1
Last Name
First Name
Gender
Date of Birth
Please select the weeks that your child will be attending Summer Camp.
Week 2: Jun 24 - 28Week 3: Jul 8 - 12Week 4: Jul 15 - 19Week 5: Jul 22 - 26Week 6: Jul 29 - Aug 2
Does your child wear diapers or pull-ups?
YesNo
Does your child have asthma, allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
Please upload your child’s current health form (from their last physical).
Note: If you are unable to upload the health form at this time, please email it to Andrea Shapiro when it's available.

ADD ANOTHER CHILD.

Yes
Child 2
Last Name
First Name
Gender
Date of Birth
Please select the weeks that your child will be attending Summer Camp.
Week 2: Jun 24 - 28Week 3: Jul 8 - 12Week 4: Jul 15 - 19Week 5: Jul 22 - 26Week 6: Jul 29 - Aug 2
Does your child wear diapers or pull-ups?
YesNo
Does your child have asthma, allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
Please upload your child’s current health form (from their last physical).
Note: If you are unable to upload the health form at this time, please email it to Andrea Shapiro when it's available.

ADD ANOTHER CHILD.

Yes
Child 3
Last Name
First Name
Gender
Date of Birth
Please select the weeks that your child will be attending Summer Camp.
Week 2: Jun 24 - 28Week 3: Jul 8 - 12Week 4: Jul 15 - 19Week 5: Jul 22 - 26Week 6: Jul 29 - Aug 2
Does your child wear diapers or pull-ups?
YesNo
Does your child have asthma, allergies or take medications on a regular basis?
YesNo
Allergy and Medication Information
My child is allergic to:
Allergy 1:
Type of Reaction:
Treatment:

Allergy 2:
Type of Reaction:
Treatment:

Allergy 3:
Type of Reaction:
Treatment:
Please upload your child’s current health form (from their last physical).
Note: If you are unable to upload the health form at this time, please email it to Andrea Shapiro when it's available.