NPBC Building STEA2M Summer Camp 2020

Camp Registration Form

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* 1. Camper First Name

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* 2. Camper Last Name

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* 3. Camper Gender

Female

Male

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* 4. Camper Birthdate (MMDDYYYY)

Date / Time

Date

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* 5. Family Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 6. Camper Grade for Fall 2020

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* 7. Camper Current School

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* 8. Camper Ethnicity

African American

Hispanic

Caucasion

Mixed

Other (please specify)

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* 9. Emergency Contact Name

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* 10. Emergency Contact Number

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* 11. Does your child have any food allergies or medical conditions we should be aware of?

Yes

Please specify

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* 12. Which weeks to you plan to attend? Check all that apply.

Week 1: June 1st - June 5th

Week 2: June 8th - June 12th

Week 3: June 15th - June 19th

Week 4: June 22nd - June 26th

Week 5: June 29th - July 2nd (short week: $128)

Week 6: July 6th - July 10th

Week 7: July 13th - July 17th

Week 8: July 20th - July 24th

Week 9: July 27th - July 31st

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* 13. We will likely need before care (7:30-8:30 am)

Yes

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* 14. We will likely need after care (4:30 - 5:30 pm)

Yes