Summer Camp Scholarship Requests
Email address *
Your name *
Your phone number *
Your email address *
Child's First Name *
Child's Last Name *
Grade camper is going into this fall? *
Child's birth date *
MM
/
DD
/
YYYY
Any pertinent medical information? *
By filling this out I understand that food will be consumed during camp and I have disclosed my child's known allergies and medical information. (allergies, prescription medicine, etc.) *
Child's Primary Physician (Doctor Full name) *
Physician's Phone Number *
Health Insurance Carrier ** Please put full company name *
Policy Number *
Any Other Pertinent Information (Special Accommodations) *
Who is allowed to pick up the child *
Emergency Contact (Full Name) *
Emergency Contact Relationship *
Emergency Contact Phone Number *
Have you read our Camp Policies and understand you will be automatically charged $15 per fifteen minutes past the pick-up time for your child’s camp. *
I give my permission to take photographs and/or videotape of my child. I understand that the photos and/or tape may be used for marketing purposes. There is no expiration date on this release and I will not seek compensation for usage. *
Please upload a copy of your drivers license to this form. *
Required
Please upload a copy of your ACCESS card to this form. *
Required
I understand that I will be contacted by Whitaker Center's Education Staff to collect my payment information. Your reservation will not be complete until your transaction is processed.
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