2019 Southlands Steam in Nature Camp
Please fill out a form for each child attending our Steam Program
Please note registration is NOT complete until deposit is received ($200 non-refundable deposit per week, per child)

If you would like to pay online, please follow this link: https://quickclick.com/r/nq77t

Refund (minus $200 deposit) given if cancellation is received at least 3 weeks prior to the start of your registered session. If cancellation is received after this time, no refund is granted.

Due with each registration is a $200 non-refundable deposit per week, per child. The remaining balance is due by June 15, 2019.

If registering after June 15, 2019- full payment is due upon registration.

If paying by check, send payment in full to:
The Southlands Foundation
5771 Route 9
Rhinebeck, NY 12572

Email address *
Camp Rate
- $600
- $575 per week if registering siblings or if registering for multiple weeks
- $560 per week for 2019 members of Southlands (Red Ribbon level or higher)
Camp Sessions
Camp hours are from 9:00 am - 3:00 pm M-F
From the list below, please check the week(s) that your child will attend *
Camper Information
Child's Name *
Your answer
Child's Age at Start of Camp *
Your answer
Birth Date *
Parent or Guardian's Name(s) *
Your answer
Parent or Guardian's Cell Phone Number(s) *
Your answer
Parent or Guardian's Home Phone Number *
Your answer
Parent or Guardian's Email *
Your answer
Parent or Guardian's Home Address *
Your answer
Emergency Contact (List name and phone number) *
Your answer
Does your child have any physical, developmental, or learning challenges that might make some activities difficult? If so, please explain: *
Your answer
Does your child need to have medication administered or available while at camp? If so, please specify . *
Your answer
What is your child's T-shirt size?
We love to take pictures at Southlands! Throughout the summer, we will take photos and share them on our website and on facebook to promote our programs. *
How did you hear about our program? *
Your answer
Choose your payment option
Registration is not complete until payment is received. Go to: https://quickclick.com/r/nq77t to pay online or write a check to: The Southlands Foundation, 5771 Route 9, Rhinebeck, NY 12572
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service