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Summer Camp Registration Form

Date: June 2nd - August 1st

Time: 7:30 am - 5:00 pm

Ages: 3 - 7 years old

Registration Cost: $50.00

Weekly Cost: $200.00

Location: 610 18th Street, West Point, VA 23181

Healthy breakfast, lunch, and snacks are provided!

**Registration Deadline/Deposits: April 30th

Please visit our Main Office (602 Main Street, West Point, VA 23181) OR Smart Start Learning Center (610 18th Street, West Point, VA 23181) to make the deposit payment.

Student Information

First Name*

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Birth Certificate Number*

Answer Required

Age/Grade*

Answer Required

Allergies/Dietary Restriction/Medical Concerns*

Answer Required

Parent Information

First Name*

Answer Required

Last Name*

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Email Address*

Answer Required

Phone Number*

Number Required

Emergency Contact (If Parent Cannot Be Reach) - Name, Phone Number, Relationship to Camper*

Answer Required

As parent/guardian having legal custody of the camper named, who is voluntarily enrolled as a participant in the PCDC Summer Camp program, I agree to instruct my child to observe rules and regulations governing the activities. I understand that camp programs involve inherent risk and possible injury because of the nature of the activity, even when conducted in a safe manner. I give permission for my child to attend camp and participate in all phases of the program. I understand that a statement of his/her good health is required before he/she may attend camp. As the parent or legal guardian of the above child, I give permission for the above child to be photographed and/or audio/video taped during this event. I also give permission for the images and/or recordings to be published, reproduced, or distributed by PCDC and its affiliates in all outlets, including, by not limited to, television, newspapers, internet, council publications, recruitment materials, and ads, without liability or limitation or claims on my part or that of my child.*

Answer Required

I have read the above statements.

I understand the information and agree to allow my son/daughter to participate in camp and give permission to images and/or recordings being published.

I understand the information and agree to all my son/daughter to participate in camp, but I DO NOT give permission to images and/or recordings being published.

Signature*

Signature Required

Confirmation Email

Confirmation Email *

Email Required