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Camp Enrollment
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*
(First & Last Name)
Child's Nickname
Child's Gender *
Child's Date of Birth *
MM
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DD
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YYYY
Parent's Name *
First & Last Name
Home Address
Email Address *
Phone Number *
How did you find us? *
Local Emergency Contact *
Name and phone number
Food Allergies *
Chronic Physical problem/Pertinent developmental info/ communicable diseases/ special accommodations deeded?
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Allergies or intolerance to food or medications etc.:
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Medications child takes:
Additional Comments
PA day/ Drop & Shop
If you apply for one day camp
MM
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DD
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YYYY
Time
:
Winter Camp
If you apply for one or more weekly camp
March Break Camp
Summer Camps
If you apply for one or more weekly camp in 2019
Weekly Camp Time
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Promo Code
Authorization & Waiver (please read & sign) *
• I, for myself, heirs, executor, trustees, administrators, successors and assigns, waive any claims to which I may become entitled for injury or damage, and hereby release Explore Center and all their representatives, agents, instructors and directors and any other persons assisting in providing the programs, from any claims for damages or injury suffered by me as a result of my participation in the programs. I also hereby give my permission for the free use of my name, image and artwork in any broadcast, telecast, website, newsletter, newspaper, media or other form of publicity. I hereby certify that I am in good health and able to participate in the Explore Center programs. I hold the Explore Center harmless for any damages or injuries sustained on any activities. In case of any accident, Explore Center has my authorization to secure, at my expense, such medical attention as is deemed necessary for the individual named on this form. • I agree to a $1 a minute late pickup or early drop off fee. • All children must be signed in and out by a parent/guardian/designated person each day. • I have carefully read and understood terms of my enrollment in the Explore Center courses.
Registration & Payment *
Please note: Registration is not secure until a payment has been received and is subject to availability. Summer Camp registration is non-refundable. Credits or refunds will not be issued for camp days not attended.
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