Camp Summerset

Camp Application

    You will be asked below to complete this application, school authorization and medical/transportation information here for each child.
    Your child is not registered until all the information is submitted along with payment.

    Step 1:

    Parent's First Name*:
    Parent's Last Name*:
    Address*:
    City*:
    State*:
    Zip*:
    Email Address*:
    Parent's Home Phone*:
    Parent's Cell Phone*:
    Child Information:
    Child's First Name*:
    Child's Last Name*:
    Child's Current Grade*:
    Teacher's Name:
    Child's Date of Birth*:
    Child's School*:
    School Address*:
    City*:
    Zip*:
    Interested in:
    My child would like to be in the same group as (Choose one friend. Will try to accommodate:
    Has your child attended camp before?:
    May we have permission to contact your child's teacher?:
    May we have permission to publish your child's photo in future camp brochures or camp materials?:
    Please indicate how you heard about us.*:
    Please Note: Your child will not be registered until all forms are processed and payment is received.
    The Language Arts Assessment will be sent with your invoice. Please be sure to send it to your child's teacher and ask that it be returned to Camp Summerset.

    Step 2: SCHOOL AUTHORIZATION FORM

    I give permission for my child’s teacher to complete the Language Arts Assessment form for my child and return it to Camp Summerset/The Learning Institute. This form is used for placement of my child at Camp Summerset and for no other purposes.
    Please Note: Your child will not be registered until all forms are processed and payment is received.

    Step 3: MEDICAL AND TRANSPORTATION FORM

    Please be advised that all information on this form will be kept confidential. Answer all the questions, sign, and return with your application.
    Child Name*: Date of Birth*:
    Present Grade:
    Street Address*: City:
    State: Zip:
    Phone Number*: Email*:
    Is your child allergic to ANY foods or medicine?:
    Is your child allergic to BEE STINGS? :
    Does your child take any medication?: (If yes, please provide details)
    Any physical activity he/she cannot participate in? :
    Any other important health related information? :
    Persons AUTHORIZED to pick up my child
    1.
    2.
    3.
    Name & Phone # of Doctor:
    In case of emergency, we can be reached at the following phone numbers:
    1: 2: 3:
    If I CANNOT be reached, call
    Or call
    Parents or Guardian Authorization: In case of emergency, if family physician CANNOT be reached, I hereby authorize my child to be treated by “CERTIFIED EMERGENCY PERSONNEL” (i.e. EMT, first responder, ER Physician)
    Parent Signature*: Date*:
     
    If you prefer to pay by check, please click SUBMIT and then mail your payment to The Learning Institute c/o Registrar
    PO Box 186 Goldens Bridge, New York 10526