APM Summer Camp Registration Form
Helping Students Achieve Their Dreams (July and August)
Choose A Location *
Legal First Name and Last Name: *
Camper only
Your answer
Preferred Name:
Your answer
Age: *
Participant only
Your answer
Gender *
Participant only
Current School
Name of participants current school.
Your answer
Home Phone:
Your answer
Mobile Phone:
Your answer
Home Address
Your answer
Postal Code
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Email Address:
Please confirm Email Address. (Confirmation of Registration will be sent to Email Address)
Your answer
Date of Birth
MM
/
DD
/
YYYY
T-Shirt Size:
Please Choose One.
Allergies/Illnesses
Please Specify: (If none please specify)
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Special Dietary Accommodations:
If none, please specify:
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Health Card #:
Your answer
Does your child acquire extra staff assistance at school?
If Yes? You will be contacted in 24 hours on confirmation of student to staff support. All students benefit when their parents or care givers get involved in supporting their summer education. This is especially important if your child has a disability.
Pick Up and Drop Off Permission:
Please let us know the first name and last name of individuals given permission to pick up your child from camp or If your child has permission to walk home.
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Emergency Contact Name:
Your answer
Emergency Contact Telephone:
Your answer
Emergency Contact Relation to the Camper
ex. mother, father, grandmother
Your answer
Name of Person Registering Child:
Your answer
Are you this child's parent or guardian?
Telephone Contact
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Please Confirm Email Address *
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Please Select the Weeks you are interested in: *
2 weeks minimum is required.
Required
Payment Options *
In order to complete registration payments must be completed before June 30th 2019
Payment Methods *
Payments are due by June 30th 2019
Please Request your Payment Plan *
Comments
Please Include Comments/Request that you would like us to know?
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