Submitted by Randy3281@ on Thu, 01/17/2019 - 15:11 Return to Main Page Before filling out the Registration information below, download and read the Summer Camp Parent Agreement. Then check the box 'I have read and agree to the terms of the Parent Agreement'. If you prefer, you can use the 'Pay Online' button found on this page to pay before or after submitting the Registration Form. After filling out and submitting the Registration Form, you will be given the opportunity to 'pay your registration online'. 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. Terms * I have read and agree to the terms of the Parent Agreement. 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. If prefered, you can download and fill out the electronic PDF Registration Form. Then upload and email using the upload feature on this page. Fees: Lacrosse Camp -- $250 AM Care – 7:00-8:30 AM -- $20/week PM Care – 4:30-6:00 PM -- $20/week Late Fee -- $20 – Starting May 31 What to Bring: Lacrosse Equipment (Goggles for girls) (Helmet and gloves for boys) Mouth Guard Water Bottle Lacrosse Stick Modest Swimsuit Towel Sunscreen Extra Set of Clothes Multiple Children Discount -- $10 off of 2nd or more children registered Will you Need AM care? * - Select -YesNo Will you Need PM care? * - Select -YesNo Billing Contact Name * Phone Number * Email * Payment, registration form and emergency form are required at registration. Any changes to this registration form must be approved by the office. Camper's Name * Birthdate * Grade Entering * Address * Phone Number * LACROSSE CAMP EMERGENCY FORM 2019 Camper's Name * Grade Entering * Mother/Guardian Name * Email * Address * Phone Number * Alternate Phone Number * Father Guardian Name * Email * Address * Phone Number * Alternate Phone Number * Emergency Contact #1 * Phone Number * Emergency Contact #2 * Phone Number * Camper's Physician/Medical Care Provider * Phone Number * Address * Date of Last Tetnus Booster * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20092010201120122013201420152016201720182019 Insurance Provider * Member/Policy Number * Allergies Medical or Dietary Information Behavioral, Learning or Physical Issues 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 * CAPTCHAHelps to prevent automated submissions. What code is in the image? * Enter the characters shown in the image.
717-235-3656717-235-3656
