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Camp Crawdad After School Enrichment
We are excited to offer an After School enrichment program at DuPont Park from the 2023 - 2024 school year. Please complete all sections of the registration form. You will receive an informational email once your application has been processed. We have limited spots available. If you have questions regarding the program, please email DERC President and Program Director (Amanda Bell-Williams) at campcrawdad@myyahoo.com
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Student Information
Please complete all questions in this section. If you have multiple children to register, you will have to complete a new registration for each child.
Student Name
Your answer
Student Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
What school does your student attend?
Blennerhassett Elementary
Blennerhassett Middle School
Other:
Clear selection
Parent/Guardian Information
Parent/Guardian #1 Name
Your answer
Parent/Guardian #1 Address
Your answer
Parent/Guardian #1 Cell Phone Number
Your answer
Parent/Guardian #1 Email Address
Your answer
Parent/Guardian #2 Name
Your answer
Parent/Guardian #2 Address
Your answer
Parent/Guardian #2 Cell Phone Number
Your answer
Parent/Guardian#2 Email Address
Your answer
Medical Information
All children attending will need an updated vaccination record on file. If your child attended the Camp Crawdad Summer program then we have a vaccination record on file.
Medical Information - Please explain any allegories, medications, disability, or developmental information that will help us provide an enjoyable experience for your child. If medication is required, we must have a doctor's order on file.
Your answer
Does your child require any special dietary requirements? If yes, a doctor's order is required.
Yes
No
Clear selection
Emergency Contact/Authorized Pick-Up Information
Please provide contact information for emergency contact/authorized pick-ups for people other than the parents/guardians listed above. Only parents/guardians and authorized pick-ups will be permitted to pick your child up from Camp Crawdad.
Emergency Contact #1 - Name
Your answer
Emergency Contact #1 - Phone Number
Your answer
Emergency Contact #2 - Name
Your answer
Emergency Contact #2 - Phone Number
Your answer
Center Information
Do you have a Procare Account?
Yes
No
Clear selection
Are you a DERC member?
Yes
No
Clear selection
Will your child be attending full-time (4 or 5 days a week)?
Yes
No
Clear selection
Will your child be attending part-time (1 to 3 days a week)?
Yes
No
Clear selection
Which days will your child be attending?
Monday
Tuesday
Wednesday
Thursday
Friday
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