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Westport Paddle Camp Registration 2021
Please complete the following information as thoroughly and accurately as possible.
The information you provide will help us care for your child in the event of an emergency.
Please call us with any questions 203-998-1519
YOUR SPACE IS NOT RESERVED UNTIL YOU HAVE PAID IN FULL
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Email
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Your email
Child's Last Name
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Your answer
Child's First Name
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Your answer
Child's Date of Birth
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MM
/
DD
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YYYY
Address, City, ST, Zip
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Your answer
First Parent/Guardian Name
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Your answer
First Parent/Guardian Cell Phone Number
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Your answer
Second Parent/Guardian Name
Your answer
Second Parent/Guardian Cell Phone Number
Your answer
Emergency Contact Info And Medical Information.
Please share any and all information with us that will help us care for your child and keep them safe.
Emergency Contact Name
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Your answer
Emergency Contact Phone
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Your answer
Allergies, Limitations, and Medications
Please bring in medications that your child would need during camp. They will be held by the lead counselor in your child's group.
Does your child have any known allergies? If yes, please list here.
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Your answer
Does your child have any physical limitations? If yes, please explain here.
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Your answer
Please list any medications or conditions that we should be aware of.
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Your answer
Carpooling is optional. List authorized names for child pick-up with phone and cell numbers *Ex. John Doe 203-333-555; Sharon Jones 203-222-7777
Your answer
Special Requests: If you would like to add an additional child or request that your child be placed with another child, please mention it here, along with their age and gender.
Your answer
Read and check that you understand and agree. *Checking this box serves as your electronic signature to the statement below.
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I understand that my child will be suspended from Westport Paddle Camp if I fail to adhere to the guidelines set forth in the Westport Paddle Camp parent manual. Inappropriate behavior will not be tolerated and is grounds for immediate dismissal.
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