Roomie's REC Camp - Spring Break 2019
Monday-Friday, April 22-26
Hours 8:00 AM - 4:00 PM
Weekly Rate: $160/week

Extended Care available:
Before Care - 6:45am-7:45am - $15/week
After Care - 4:15pm-6:00pm - $15/week

Email address *
Today's Date: *
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Child's Last Name *
Your answer
Child's First Name *
Your answer
Gender: *
Child's Age: *
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Parent's/ Guardian's Name(s) *
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Phone Number *
Your answer
Home Address *
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City *
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Zip Code *
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In Case of Emergency, specify Persons authorized to pick up your child:
Name, Relationship, & Phone Number
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Medical Information: Check any that apply to your child *
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Please explain any medical conditions.
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Please list any medications your child is taking, including over-the-counter meds:
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Do you know of any health factors that make it advisable for your child to follow a limited program of physical activity or to refrain from participating in any activities? If yes, please explain. Also, please mention any recent surgeries, broken bones, injuries, allergies or other physical conditions.
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Name and Phone # of your camper's primary physician *
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