Summer Camp

Person Paying Details

Please provide information about the person who is responsible for paying for child's summer camp registration

Name(Required)

First Last

Email(Required)

Phone

Camper Information

Please provide information about child (ages 6-17) who your registering for camp.

Camper's Name(Required)

First Last

Gender(Required)

School Name

Grade

Birth Date(Required)

Age

Camper Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Camper Home Phone

Child lives with

Parent / Guardian 1

Please provide contact information of child's Parent or Guardian #1

Parent / Guardian 1 Name(Required)

First Last

Parent / Guardian 1 Address(Required)

Same as Camper's Home Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone(Required)

Parent / Guardian 1 Email

Parent / Guardian 1 Occupation

Parent / Guardian 1 Employer

Parent / Guardian 2

Please provide contact information of child's Parent or Guardian #2

Parent / Guardian 2 Name(Required)

First Last

Parent / Guardian 2 Address

Same as Parent / Guardian 1 Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Parent / Guardian 2 Email

Parent / Guardian 2 Occupation

Parent / Guardian 2 Employer

Emergency Contact Information

Emergency Contact Information / Alternate Pickup Release

Primary Emergency Contact Name(Required)

First Last

Cell Phone(Required)

Primary emergency contact's cell phone number

Home Phone

Primary emergency contact's home phone number

Work Phone

Primary emergency contact's work phone number

Email(Required)

Primary emergency contact's email address

Primary Contact's Relation to Camper(Required)

Secondary Emergency Contact Name(Required)

First Last

Cell Phone(Required)

Secondary emergency contact's cell phone number

Home Phone

Secondary emergency contact's home phone number

Work Phone

Secondary emergency contact's work phone number

Email(Required)

Secondary emergency contact's email address

Secondary Contact's Relation to Camper(Required)

Authorized Alternate Pickup Persons

Please list up to 3 other people in addition to parents/guardians who are permitted to pick up your child:

Medical Release Information

Please provide medical release information for your child. The purpose of the this information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Policy Number(Required)

Health Insurance Provider(Required)

Please provide the name of the health insurance provider.

Primary Physician(Required)

Please provide primary physician's name or the name of practice

Primary Physician Address

Physician Phone(Required)

Hospital Preference

Medical Problems(Required)

Please list any medical problems your child may have, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). Please mention if paramedic should be called to address any of these medical issues.

Provide details if your child being treated for injury or sickness(Required)

You may enter "NONE" if your child is not being treated for an injury or sickness or taking any form of medication for any reason.

Please list any allergies to food or medicine(Required)

If your child has no allergies please enter "NONE"

Please list any required dietary needs(Required)

If you child has any special dietary needs please provide details otherwise you may enter "NONE"

Payment Details

Hidden

Early Bird Date

Payment Options(Required)

Pay In Full ($295)

Deposit ($105)

If selecting Deposit, second installment ($95) is due not later than May 15, 2023 and final payment ($95) must be paid no later than May 31, 2023.

Total

Phone

This field is for validation purposes and should be left unchanged.

Rizing Gen Summer Camp 2023

Person Paying Details

Camper Information

Parent / Guardian 1

Parent / Guardian 2

Emergency Contact Information

Medical Release Information

Payment Details