Summer Program Application Form

Date

Month

Day

Year

Child's First Name

Child's Last Name

Age

Grade

Allergies

Parent's Name(s)

Address

Primary Phone Number

Emergency Contact Name

Emergency Contact Number

I give permission for my child to go on all walking trips.

Acknowledge

Print Name as Signature

Cost of program is $1,875.00 PLUS Registration and Activity Fee

All program fees must be paid in full OR in 2 (two) installments:

Activity Fee: $40.00 per week, Total of $200.00 CASH ONLY due by 7/8/25.

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Non refundable registration fee due with form is $125.00 after 5/1. Registration fee is $100.00 before 5/1.

Name of Child

Age of child (Must be 5 by July 1st)

Parent's Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Cell Phone

Emergency Name

Emergency Phone