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Camp Enrollment
Child Name *
(First & Last Name)
Your answer
Child's Nickname
Your answer
Child's Gender *
Child's Date of Birth *
MM
/
DD
/
YYYY
Parent's Name *
First & Last Name
Your answer
Home Address
Your answer
Email Address *
Your answer
Phone Number *
Your answer
How did you find us? *
Local Emergency Contact *
Name and phone number
Your answer
Food Allergies *
Chronic Physical problem/Pertinent developmental info/ communicable diseases/ special accommodations deeded?
*
Allergies or intolerance to food or medications etc.:
Your answer
*
Medications child takes:
Your answer
Additional Comments
Your answer
PA day/ Drop & Shop
If you apply for one day camp
MM
/
DD
/
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
Promo Code
Your answer
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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