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Rooted Village Camp: Week 1 (July 10-12)
Please note that you will be invoiced once this form is submitted and a waiver will be sent for signature
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* Indicates required question
What Day/s Will you Attend? Please Check all that Apply
*
Monday 7/10
Tuesday 7/11
Wednesday 7/12
Required
Child Name (First, Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian Name
*
Your answer
Parent/Guardian Contact #
*
Your answer
Parent/Guardian Email Address
*
Your answer
Emergency Contact (Name, Phone, Address, Relationship to child)
Your answer
Does the Child have Allergies? Please list.
Please write "NKA" if No Known Allergies
*
Your answer
Physician Name/Phone Number
Your answer
Is There Anything we Need to Know About your Child?
(ASD, ADHD, Hard of Hearing/Sight,
Anxiety, etc.)
Should be listed here.
Your answer
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