Jackson Memorial Library Summer Camp Registration Session 1-Outdoor Art July 18-July 20
Please complete all blanks on this form. If there is a blank that is not applicable, please write N/A in the blank.
Open to Ages: 8 to 12
Times: 9am to 3pm
Dates:
Session 1-Outdoor Art July 18-July 20

Spots will be filled on a first come, first serve basis. There are only 12 slots available per session.
Cost per session = $100/child

Email address *
Child's Information
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Child's Address including city/state/zip *
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Home Telephone Number *
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Parent/Guardian
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Guardian #1
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Guardian Full Address including city/state/zip *
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Guardian Phone #2
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Emergency Contact or Guardian #2
Emergency Contact Name *
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Emergency Contact Address *
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Emergency Contact Phone #1 *
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Emergency Contact Phone #2
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Additional Information
Please list persons authorized for pick-up of child (in addition to guardians listed above)
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Medical Information
Does your child have any allergies and/or intolerances to food, medication or any other substances? What are the symptoms and action to be taken if any?
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Please provide information on chronic physical and pertinent developmental information and any special accommodations needed.
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Please check here if you child will be required to take medication during the camp day (medical authorization form also required)
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Please select which session your child would like to attend
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Once you submit this form your child is on the list, but their space is not reserved until we receive payment and a signed waiver from the parent or guardian.
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