B.A.S.E. Summer Camp Registration

Parent Contact Information:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Address Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Preferred language for communication: English Spanish

Preferred method of contact: Email Phone

Emergency Contact Information:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

STUDENT INFORMATION:

1. Child's Name Please enter valid data.

Allergies Please enter valid data.

Grade entering Fall 2022

Attendance Options: Full Day 7:30-5:30PM (5 days per week) Half Days 9:00-1:00PM (5 days per week) Single Day(s) Please fill out days needed in space below

Single Camper day(s) needed: Please enter valid data.

2. Child's Name Please enter valid data.

Allergies Please enter valid data.

Grade entering Fall 2022

Attendance Options: Full Day 7:30-5:30PM (5 days per week) Half Days 9:00-1:00PM (5 days per week) Single Day(s) Please fill out days needed in space below

Single Camper day(s) needed: Please enter valid data.

3. Child's Name Please enter valid data.

Grade entering Fall 2022:

Allergies Please enter valid data.

Attendance Options: Full Day 7:30-5:30PM (5 days per week) Half Days 9:00-1:00PM (5 days per week) Single Day(s) Please fill out days needed in space below

Single Camper day(s) needed: Please enter valid data.

4. Child's Name Please enter valid data.

Allergies Please enter valid data.

Grade entering Fall 2022

Attendance Options: Full Day 7:30-5:30PM (5 days per week) Half Days 9:00-1:00PM (5 days per week) Single Day(s) Please fill out days needed in space below

Single Camper day(s) needed: Please enter valid data.