Jackson Memorial Library Summer Camp Registration Session 2-Getting Dirty July 25-July 27
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 2-Getting Dirty July 25-July 27

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

Child's Information
Child's Full Name
Your answer
Child's Address including city/state/zip
Your answer
Home Telephone Number
Your answer
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian
In the event of an emergency
Guardian #1
Guardian Full Name
Your answer
Guardian Full Address including city/state/zip
Your answer
Guardian Phone #1
Your answer
Guardian Phone #2
Your answer
Emergency Contact or Guardian #2
Emergency Contact Name
Your answer
Emergency Contact Address
Your answer
Emergency Contact Phone #1
Your answer
Emergency Contact Phone #2
Your answer
Additional Information
Please list persons authorized for pick-up of child (in addition to guardians listed above)
Your answer
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?
Your answer
Please provide information on chronic physical and pertinent developmental information and any special accommodations needed.
Your answer
Please check here if you child will be required to take medication during the camp day (medical authorization form also required)
Please explain
Your answer
Please select which session your child would like to attend
Registration Almost Complete
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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