Summer in the Son CAMP REGISTRATION
Camper's Name *
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Parent's Email *
Home Phone Number *

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EMERGENCY CONTACT INFORMATION

In case of emergency, Summer in the Son needs the following information:
Mother's Name
Prefix
First
Last
Suffix
Place of Employment
Work Phone Number

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Mobile Phone Number

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Father's Name
Prefix
First
Last
Suffix
Place of Employment
Work Phone Number

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Mobile Phone Number

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INSURANCE INFORMATION

Please list information on the policy which covers the camper
Insurance Company Name
Policyholder Name
Policy #

MEDICAL FORM

Family Physician Name
Physician Phone Number

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Date of Last TETANUS immunization

MM		/
DD		/
YYYY
Date of Last POLIO BOOSTER

MM		/
DD		/
YYYY
Does the camper have a history of any of the following?
 Asthma 
 Sinusitis 
 Bronchitis 
 Diabetes 
 Other - please list below 
Please list any additional MEDICAL HISTORY information below.
ALLERGIES - Please check all that apply
 Food 
 Drugs 
 Insects 
 Other - please list below 
Please list any additional ALLERGY information below.

GENERAL INFORMATION

Camp Fees are due on the FIRST DAY OF THE WEEK.
A $10 Late Fee will be applied if fees are not paid byTuesday evening.
A $30 Returned Check Fee will be applied on all returned checks
A $10 Late Pick-up Fee will be applied to all pick-ups after 6:00pm

IMPORTANT REGISTRATION INFORMATION

Camp Registration is NOT COMPLETE until the Registration Fee is received by our office and Permission Forms are signed. Please call our office @ 556-6802 between 9am-12pm on weekdays to set a time to stop by and pay Registration Fee & sign Permission Forms.
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