Kids Camp Enrollment Form
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2Kids Camp Enrollment Form
Explorer (6yr-12yr)_____
Jr. Explorer (3yr– 5yr)_____
Today’s Date
: ____________________
Camper Information
Full Name: _________________________________________________________________Grade Just Completed: _____________
Phone Number: __________________________ Birth Date: __________________________
Gender: F
M
RESIDENTIAL PARENT / GUARDIAN INFORMATION
Full Name: __________________________________________ Relationship to student: __________________________
Contact Numbers: __________________________
Work Cell Home ______________________________________ Work Cell Home
Full Name: __________________________________________ Relationship to student: __________________________
Contact Numbers: __________________________
Work Cell Home ______________________________________ Work Cell Home
Address: ___________________________________________________________________________________________
Primary Billing Email Address: _________________________________________________________________________
EMERGENCY CONTACTS (other than parent/guardian)
Name: _________________________________________ Phone: ________________________
Authorized to pick up? Y N
Name: _________________________________________ Phone: ________________________
Authorized to pick up? Y N
Name: _________________________________________ Phone: ________________________
Authorized to pick up? Y N
MEDICAL/INSURANCE INFORMATION
__________________________________________________
_________________________________________________
Physician
Physician Telephone Number
___________________________________________________
_________________________________________________
Medical Insurance Name
Medical Group/Policy Number
________________________________________________________________
_____________________________________________________________
Medical Insurance Policy Holder
Medical Insurance Telephone Number
________________________________________________________________
_____________________________________________________________
Food Allergies
Other Allergies or Medical Conditions
Any changes that need to be made to the dates your child is enrolled must be submitted using the 2016
Summer Camp Change form at least 1 week prior to the change date.
I understand that I will be invoiced for the days that my child is enrolled in summer camp, regardless of
attendance. Credits will only be given when a change form has be submitted at least 1 week prior to the
change. Additional field trip fees are listed on the camp calendar and will only be billed after attended.
_____________________________________________________________
_________________________________
Parent/Guardian Signature
Date
19741 BAKER ROAD
◊
BEND, OR 97702
◊
PHONE: 541. 382. 5091
◊
FAX: 541. 382. 0268
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