Summer Camp Registration

Please use the following form to register. Once you have submitted the application, you will need to contact our office to arrange payment of registration fees & your child's first week of tuition. Note: Completed applications submitted without payment will not hold your child's spot in our program. You must complete the application AND arrange for payment to ensure your child is registered

Child’s Information

Child’s Name
Child’s Age
Grade entering
this Fall
T-Shirt Size

Parent/ Guardian Contact Information

Parents Name(s)
Address
Address /Apt. #
City
State/Province
Zip/Postal Code
Home Phone
Work Phone
Cell Phone
Email

Secondary Emergency Contact Information

Name(s)
Address
Address /Apt. #
City
State/Province
Zip/Postal Code
Home Phone
Cell Phone
Relationship

Additional Emergency Contact Information

Name(s)
Address
Address /Apt. #
City
State/Province
Zip/Postal Code
Home Phone
Cell Phone
Relationship

Please check only the weeks your child WILL be attending camp.

Week 1 (June 11th - June 15th)
Week 2 (June 18th - June 22nd)
Week 3 (June 25th - June 29th)
Week 4 (July 2nd - July 6th)
Week 5 (July 9th - July 13th)
Week 6 (July 16th - July 20th)
Week 7 (July 23rd - July 27th)
Week 8 (July 30th - August 3rd)
Week 9 (August 6th - August 10th)
Week 10 (August 13th - August 17th)

Allergies / Medical Conditions

Please list any and all allergies or medical conditions

Release for Pick Up

Please name up to 3 people in addition to you or your spouse who may sign out your child from our center without prior written permission. These individuals will be allowed to remove your child from our care without contact from you, after showing a valid driver’s license.

Name & Relationship
Name & Relationship
Name & Relationship

Please notify the Director in writing of any persons who are to have no contact with your child. Please include a copy of any No Contact Order per any court decision. This includes custody disputes.

By clicking "Submit Form" below, you state that you have read and agree to the rules and conditions outlined in the:

Kid Space Summer Camp Policies and Procedures.

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