Summer Story Camp 2018 Registration Form
A program of the Southwest Harbor Public Library

**Story Camp runs Monday - Friday from 9am-12noon. Before care is available from 8am-9am. Pick up and drop off is at the Southwest Harbor Library

**Space is limited to 15 campers each week. Your registration form will be used to assign your child one week of camp based on your first choice and availability. If additional space is available you will be notified if your child will be offered a second week.

**Summer Story Camp costs are covered by donations from community organizations. Donations of any size are welcome and appreciated.

You will receive confirmation of your completed registration by email, and we will contact you within a week of receiving your registration to confirm your Summer Story Camp 2018 Week.

For inquiries or more information, please email Crystal Dagraca at cdagraca@mdirss.org or call Susan Plimpton at the Library at (207) 244-7065.

Name of Camper *
Your answer
Camper Date of Birth *
MM
/
DD
/
YYYY
Camper's Age on June 1st *
Your answer
Parent/Guardian Name(s) *
Your answer
Home Address *
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
Parent/Guardian Email Address *
Your answer
Southwest Harbor Library Card Number
(Required to complete registration. Easy to do - just come by! Please complete this by June 1st.)
Your answer
Registration Week - Check off 1st Choice Week *
Required
Registration Week - Check off 2nd Choice Week
Please note: if there is availability, we will register your camper for a second week. This additional week is not guaranteed.
Emergency Contact Name & Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
Adults/Siblings Age 15 or over authorized to pick up your child:
Your answer
Please include additional concerns related to your child’s placement in camp, including any allergies:
Your answer
Authorization of the reproduction, for publication and use by the Southwest Harbor Public Library and their successors and assigns, for advertising, commercial and promotional use and any other purpose, any photos, pictures, or likenesses of myself or my child. Children will not be identified by name. *
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