2022 Summer Registration Form
Please complete this registration form as soon as possible and before April 30, 2022. The camp sessions are filled on a first come first served basis with regard to age (must be age 9-14) and gender. Slots fill up quickly, so don't delay. Confirmation letters will be emailed after May 1st.  

Requirements: Before any child may stay at camp, we must have copies of the physical, birth certificate, and immunization and Covid vaccine record. The health form must be signed by a physician or nurse practitioner within the last 2 years.

This is a free camp sponsored by the Downtown Kiwanis Club of Little Rock.

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Email *
Child's Last Name *
Child's First Name *
Child's Middle Name
Child's Nickname
Child's Age *
Child's Race *
Child's Sex *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Social Security Number *
Street Address with Apartment # if applicable *
City *
State *
Zip Code *
With whom does this child live? (Name) *
Emergency phone #1 *
Emergency phone #2 *
Emergency phone #3 *
Child's Current School *
Child's Current Grade *
Parent or Guardian's Email Address *
Siblings may attend the same session if space is available.  Please list any siblings that you would like to attend during the same session.  ****This does not register them for camp.  A separate registration form must be completed for each camper!!!!
Residential Camp Dates: Monday AM-Friday AM, (except July 4th week Tuesday AM-Friday PM) Please rank (in order of preference) the week that you would like to request for your child to attend camp. If there is any week that your child is unable to attend camp, please note this also by choosing "NA" next to that week. Honor Camp is by invitation only. *
1st choice
2nd choice
3rd choice
4th choice
5th choice
N/A
Session I (June 13-17)
Session II (June 20-24)
Session III (June 27-July 1)
Session IV (July 5-8)
Session V (July 11-15)
Please read these guidelines and click read and agree to move forward: Medical/Covid Protocol-All campers are required to be vaccinated for Covid-19. All campers must have a physical signed by a doctor or nurse practitioner within the last 2 years. *
Registration on Monday is from 8:30 am to 11:30 am. Parents are responsible for arranging transportation to and from the camp. Campers must be picked up on Friday between 10-11 am (no exceptions). Failure to pick up your child by 11 am will result in a $1 per minute charge for every minute you are late and may jeopardize future participation in camp programs. *
Campers may be involved in field trips outside of the camp and will be transported by camp staff as needed. The camp reserves the right to release photographs, video, and/or written information/articles of campers to be used for advertising, public relations, fundraising, or grant reporting purposes. *
Campers must adhere to the camp's rules and discipline model that emphasizes acceptance of responsibility. We reserve the right to dismiss campers early, if necessary, due to medical or behavioral issues. *
Campers are not allowed to make or receive phone calls or to have visitors while at camp. Campers are not allowed to leave camp during a camp session. No electronic devices are allowed (cell phones, etc.) *
I have read and agree to follow these guidelines and the guidelines in the camp brochure. I understand that if my child or I fail to meet those guidelines, my child may be dismissed from Pfeifer Camp. Furthermore, I authorize Pfeifer Camp and its qualified staff to render medical treatment to the camper named on the form as may, in the judgement of the camp staff, be necessary for their health and/or well-being. Please fill in your name as parent and/or guardian below: *
A copy of your responses will be emailed to the address you provided.
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