Registration Form

Please complete the form below to register.

Camper Information
Camp Name: 2014: Jumpstart Kindergarten

Price: 120.00

Name:

Age:

Date of Birth: (mm/dd/yyy)

Gender:

T-Shirt Size (Adult Size):


Parent/Legal Guardian Information
Name:

Phone Number:

Email:


Address Information
Street Address:

City:

State:

ZIP Code:


Emergency Contact Information
Primary Contact

Name:

Relationship:

Phone Number:


Secondary Contact

Name:

Relationship:

Phone Number:


List any known drug allergies or other allergies (including type of reaction) which may affect the child’s ability to participate fully in the camp.




List any medical condition(s) or medication(s) being taken which may affect the child’s ability to participate fully in the camp.





Accept Agreement
I have read and accept the terms and conditions below.

Model Release for Minors Agreement

Waiver Indemnification and Medical Treatment Authorization Agreement