Summer Camp 2021

Saint Raphael Catholic School

Summer Camp Registration

Rising 1st-Rising 8th Graders

SESSION

CAMP NAME

Session 1A

June 7-11       9:00-12:00

Session 1B

June 7-11       12:45-3:45

Session 2A

June 14-18     9:00-12:00

Session 2B

June 14-18     12:45-3:45

Session 3A

June 21-25     9:00-12:00

Session 3B

June 21-25     12:45-3:45

There is a $25.00 NON-REFUNDABLE Deposit Fee per Camp due with Registration.

# of Camps _______ x $125.00 – Deposit Fee = Balance Due _____________

(Example:  1 Camp @ $125.00 - $25.00 Deposit = $100.00 Balance Due)

My child will need:_______ Before Care ($5.00 per day)    

Camper’s Name

  Male             Female

Address

Camper’s Birth Date

 Grade in August, 2021

Parent/Guardian 1

Address

Cell #

Daytime #

Email Address

Parent/Guardian 2

Address

Cell #

Daytime #

Email Address

Family Physician

Address

Phone #

Dentist/Orthodontist

Address

Phone #

Medical/Hospital Insurance Carrier

Health History (circle all that apply)

convulsions

asthma

bleeding/clotting disorder

allergies

Restrictions on

physical activity

Current medications

Other conditions of which camp staff should be aware

In addition to Parent/Guardian names listed above, these person(s) have permission to pick up my child from camp. I understand that my child will not be allowed to leave with any other person without authorization from Parent/Guardian, and that the person picking up my child will show identification.

Name

Cell #

Relationship

Name

Cell #

Relationship

Parent/Guardian Signature                                                              

Date