Submitted by Randy3281@ on Mon, 12/09/2019 - 14:41 Special Registration Window -- Register between May 12 and May 22 to have your registration fee waived! To Register for Day Camp Before filling out the registration information below, download and read the Day Camp Parent Agreement. Then check the box 'I have read and agree to the terms of the Parent Agreement'. To complete your registration, we must receive your registration fee. You can use the 'Pay Online' button found on this page to pay before or after submitting the registration form. If you prefer to pay by personal check, please send payments to 140 S. Front St, New Freedom, PA 17349. Include your child's/children's name(s) on your check. Registration is not complete until both the registration form and payment are received. Complete the form below. After you hit the submit button (please only click it one time) you will receive a confirmation page. Please read the 2020 Day Camp Procedures and Helpful Reminders. This will help you and your campers be ready for camp! If you do not receive a welcome email from the Program Director in a few days after submitting your form, please contact Liz Downey (717-235-3656). Terms * I have read and agree to the terms of the Parent Agreement. Full Week – 4-5 Days -- $175 (8:30 am-4:30 pm) Partial Week – 1-3 Days -- $150 (8:30 am-4:30 pm) Drop off begins at 8:30 am and pick up is by 4:30 pm. AM Care – 7:00-8:30 AM -- $25 Per Week PM Care – 4:30-6:00 PM -- $25 Per Week Registration Fee -- $30 (Due with submitted registration form) Early Bird Discount – 5% off invoice if registered for 4 weeks and paid in full by first tuition due date Multiple Children Discount -- $10 per week of 2nd or more children registered NOTE: Multiple children can be registered. However, specific information is required for each child. Enter a childs name in the '#1 Camper's Name' field, hit enter, and the information required for the #1 Camper is displayed. To add a second camper enter a childs name in the '#2 Camper's Name' field, hit enter, and the information required for the #2 Camper is displayed. Repeat this process for a third or fourth Camper if required. After the individual camper content is complete, continue to complete the remaining required content. #1 Camper's Name * Pictures * - Select -Yes, I agree to let my child's image be used in camp materials.No, I do not agree to let me child's image be used in camp materials. Please mark the 'weeks' and 'childcare' options you are registering for child #1. ** Registrations for the upcoming week must be made by end of Wednesday of the previous week. ** (i.e. Week 4 - Registration by end of Wednesday June 17th.) (Week 1) Canceled (Week 2) Canceled (Week 3) June 15-19 Full Week Partial Week AM Child Care PM Child Care (Week 4) June 22-26 Full Week Partial Week AM Child Care PM Child Care (Week 5) June 29 - July 3 Full Week Partial Week AM Child Care PM Child Care (Week 6) July 6-10 Full Week Partial Week AM Child Care PM Child Care (Week 7) July 13-17 Full Week Partial Week AM Child Care PM Child Care (Week 8) July 20-24 Full Week Partial Week AM Child Care PM Child Care (Week 9) July 27-31 Full Week Partial Week AM Child Care PM Child Care (Week 10) August 3-7 Full Week Partial Week AM Child Care PM Child Care (Week 11) August 10-14 Full Week Partial Week AM Child Care PM Child Care #1 Birth Date * #1 Grade Entering * #1 Date of Last Tetanus Booster * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200920102011201220132014201520162017201820192020 #1 Allergies * #1 Medical or Dietary Information * #1 Behavioral, Learning or Physical Issues * #2 Camper's Name Pictures * - Select -Yes, I agree to let my child's image be used in camp materials.No, I do not agree to let me child's image be used in camp materials. Please mark the 'weeks' and 'childcare' options you are registering for child #2. ** Registrations for the upcoming week must be made by end of Wednesday of the previous week. ** (i.e. Week 4 - Registration by end of Wednesday June 17th.) (Week 1) Canceled (Week 2) Canceled (Week 3) June 15-19 Full Week Partial Week AM Child Care PM Child Care (Week 4) June 22-26 Full Week Partial Week AM Child Care PM Child Care (Week 5) June 29 - July 3 Full Week Partial Week AM Child Care PM Child Care (Week 6) July 6-10 Full Week Partial Week AM Child Care PM Child Care (Week 7) July 13-17 Full Week Partial Week AM Child Care PM Child Care (Week 8) July 20-24 Full Week Partial Week AM Child Care PM Child Care (Week 9) July 27-31 Full Week Partial Week AM Child Care PM Child Care (Week 10) August 3-7 Full Week Partial Week AM Child Care PM Child Care (Week 11) August 10-14 Full Week Partial Week AM Child Care PM Child Care #2 Birth Date * #2 Grade Entering * #2 Date of Last Tetanus Booster * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200920102011201220132014201520162017201820192020 #2 Allergies * #2 Medical or Dietary Information * #2 Behavioral, Learning or Physical Issues * #3 Camper's Name Pictures * - Select -Yes, I agree to let my child's image be used in camp materials.No, I do not agree to let me child's image be used in camp materials. Please mark the 'weeks' and 'childcare' options you are registering for child #3. ** Registrations for the upcoming week must be made by end of Wednesday of the previous week. ** (i.e. Week 4 - Registration by end of Wednesday June 17th.) (Week 1) Canceled (Week 2) Canceled (Week 3) June 15-19 Full Week Partial Week AM Child Care PM Child Care (Week 4) June 22-26 Full Week Partial Week AM Child Care PM Child Care (Week 5) June 29 - July 3 Full Week Partial Week AM Child Care PM Child Care (Week 6) July 6-10 Full Week Partial Week AM Child Care PM Child Care (Week 7) July 13-17 Full Week Partial Week AM Child Care PM Child Care (Week 8) July 20-24 Full Week Partial Week AM Child Care PM Child Care (Week 9) July 27-31 Full Week Partial Week AM Child Care PM Child Care (Week 10) August 3-7 Full Week Partial Week AM Child Care PM Child Care (Week 11) August 10-14 Full Week Partial Week AM Child Care PM Child Care #3 Birth Date * #3 Grade Entering * #3 Date of Last Tetanus Booster * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200920102011201220132014201520162017201820192020 #3 Allergies * #3 Medical or Dietary Information * #3 Behavioral Learning or Physical Issues * #4 Camper's Name Pictures * - Select -Yes, I agree to let my child's image be used in camp materials.No, I do not agree to let me child's image be used in camp materials. Please mark the 'weeks' and 'childcare' options you are registering for child #4. ** Registrations for the upcoming week must be made by end of Wednesday of the previous week. ** (i.e. Week 4 - Registration by end of Wednesday June 17th.) (Week 1) Canceled (Week 2) Canceled (Week 3) June 15-19 Full Week Partial Week AM Child Care PM Child Care (Week 4) June 22-26 Full Week Partial Week AM Child Care PM Child Care (Week 5) June 29 - July 3 Full Week Partial Week AM Child Care PM Child Care (Week 6) July 6-10 Full Week Partial Week AM Child Care PM Child Care (Week 7) July 13-17 Full Week Partial Week AM Child Care PM Child Care (Week 8) July 20-24 Full Week Partial Week AM Child Care PM Child Care (Week 9) July 27-31 Full Week Partial Week AM Child Care PM Child Care (Week 10) August 3-7 Full Week Partial Week AM Child Care PM Child Care (Week 11) August 10-14 Full Week Partial Week AM Child Care PM Child Care #4 Birth Date * #4 Grade Entering * #4 Date of Last Tetanus Booster * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year200920102011201220132014201520162017201820192020 #4 Allergies * #4 Medical or Dietary Information * #4 Behavioral Learning or Physical Issues * Street Address * City * State * - Select -MarylandPennsylvania Zip * Phone Number * Billing Contact Name * Phone Number * Email * Day Camp Billing Disclaimer Summit Grove will bill for all weeks marked. Any changes to this registration form must be approved by the office. After two changes, a $15 processing fee will be added for each additional change. DAY CAMP EMERGENCY FORM 2020 Mother/Guardian Name * Email * Address 'Same as Camper' * Yes No Street Address * City * State * - Select -MarylandPennsylvania Zip * Phone Number * Alternate Phone Number * Father/Guardian Name * Email * Address 'Same as Camper' * Yes No Address * City * State - None -MarylandPennsylvania Zip * Phone Number * Alternate Phone Number * Emergency Contact #1 * Phone Number * Emergency Contact #2 * Phone Number * Camper's Physician/Medical Care Provider * Phone Number * Address * Insurance Provider * Member/Policy Number * ELECTRONIC SIGNATURE If only one parent/guardian is provided for this form, that parent also certifies: I hereby certify that this application has provided only one parent/guardian because (1) I am the sole parent/guardain responsible for this child or (2) I have made a good faith effort to obtain consent from the second parent/guardian but have not been able to do so due to reasons beyond my control. Mother/Guardian Name * Today's Date * Father/Guardian Name * Today's Date * Please only click the 'Submit' button one time. CAPTCHAHelps prevent automated submissions. (Letters are case sensitive.) What code is in the image? * Enter the characters shown in the image.
717-235-3656
