2021-2022 Weekend Camp Sign-Up Form

2021-2022 Weekend Camp Sign-Up Form

Phone: 941-746-5659 | Fax: 941-745-1409
YOUR CHILD WILL NOT BE REGISTERED UNTIL A $50 NON-REFUNDABLE FEE IS PAID. Annual up to date physical MUST be turned in 2 weeks prior to the first day of camp.
CAMPER INFORMATION
How did you hear about us?
Returning Camper New Camper
Camper Name *

First Name Last Name
Sex
Height
Weight
Date of Birth *

Month Day Year
Date
Age *
Ethnicity
Disability/Primary Diagnosis *
Address *

Street Address

Street Address Line 2

City State

Zip Code
County
Parent/Guardian Name *

First Name Last Name
Email *
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Recent illness, injury, or behavioral change

BILLING AND PAYMENT
Payment Option 1- FULL PAY (I will send a check or call (941)746-5659 to pay full payment of $250 per weekend camp session or $125 per day camp session. A $50.00 portion is non-refundable.)

Payment Option 2- PARTIAL PAY (I will send a check or call (941)746-5659 to pay a $50.00 non-refundable payment to be applied to the total cost of each camp session. The balance remaining will be paid in full prior to the start of camp.)

Payment Option 3- SCHOLARSHIP/FINANCIAL ASSISTANCE NEEDED (I have a low income or financial hardship and have submitted the attached Scholarship Application Form. I will send a check or call (941)746-5659 to make payment of the non-refundable $50.00 for each camp session. I have submitted the most recent proof of income for my household.)

Payment Option 4- OUTSIDE FUNDING (I will be receiving funding through an outside source to pay. I understand I am responsible for payment for any agency funding which is not obtained.) ***You MUST provide contact information
Check the desired payment option below

Payment option 1 Payment option 2 Payment option 3 Payment option 4
If Payment Option 4 is selected, please fill out the following information:
Agency
Agency Contact Person
Agency Phone
Contact Email
example@example.com
Agency Address

Street Address

Street Address Line 2

City State

Zip Code
PLEASE READ AND SIGN: I acknowledge that acceptance into a desired camp session(s) is NOT guaranteed and is contingent upon space availability.
Signature *

Clear
Date *

Month Day Year
Should be Empty:

2021-2022 Weekend Camp Sign-Up Form

CAMPER INFORMATION

2020-2021 WEEKEND CAMP SESSIONS

BILLING AND PAYMENT