Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Registration Form

Camp Address: The Wheeler House, 1100 Dorset Street, South Burlington VT
Contact us at summercamps@commonroots.org

What is your child's name and age? *

Your name (and other caregiver's if applicable)

Your email *

Your Phone Number *

Does your child utilize any support services at school?

Yes

Clear selection

If yes, please describe those services

Emergency contact if primary caregivers cannot be reached:

Which weeks will your child be attending? *

Option 1

Option 2

Option 3

Does your child have any serious allergies or medical conditions we should know about?

Name and number of your child's pediatrician:

What is something your child loves to do/explore/learn about?

Each session (each week) costs $300 per child. We will prepare a morning and afternoon snack with the campers. Campers will bring lunch from home and their water bottle each day.

Extended-care (3:30-5:30pm) will cost $25 per hour.

Must be scheduled 48 hours in advance.

This fee is due to our lead counselor at pick up each time you utilize this service.

Drop off will always be at the Wheeler house:

Wheeler Homestead, 1100 Dorset Street

Two days a week, the pick up location will be at the Farm:

South Village Farm, 55 Allen Road East

Details to come...

www.commonroots.org

To reserve your spot, submit this form, and send your check payable to "Common Roots Inc" to:

PO Box 9335, So. Burlington, VT 05407

We will send a confirmation email when we receive it!

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms