Riverside Summer Camp Registration 2019
Please fill out this form for each child your are registering for Summer Camp at Riverside Christian Childcare. There are additional forms needed from the center after registration. We will contact you for that information once this form has been received. Please call us at (920) 339-0365 or email at riverside@stmarkpartners.org if you have questions or trouble filling out this form. Thank you!
Child's Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Parent #1 Name *
Your answer
Parent #1 Phone Number *
Your answer
Parent #1 Home Address *
Your answer
Parent #1 Workplace and Work Phone *
Your answer
Parent #1 Email *
Your answer
Parent #2 Name *
Your answer
Parent #2 Phone Number *
Your answer
Parent #2 Home Address (if different from above)
Your answer
Parent #2 Work Place and Phone *
Your answer
Parent #2 Email *
Your answer
Child's Allergies and Treatment
Your answer
Special Food Restrictions or Care Instructions
Your answer
Emergency Contact #1: *
Your answer
Emergency Contact #1 Phone: *
Your answer
Emergency Contact #1 Relationship to Child: *
Your answer
Emergency Contact #2: *
Your answer
Emergency Contact #2 Phone: *
Your answer
Emergency Contact #2 Relationship to Child: *
Your answer
Please list anyone who is NOT authorized to pick-up your child:
Your answer
Child's Physician, Phone and Address: *
Your answer
Please check appropriate boxes below regarding your child:
Please Sign and date as Electronic Signature *
Your answer
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