Parent or Guardian Name: *

First Name

Last Name

Childs Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Childs Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Camp schedule

Full time $195.00 Weekly Per Child

Part time $98.00 Weekly Per Child

Drop In $39.00 Daily Per Child

Preferred Start Date

MM

DD

YYYY

Method of payment? *

CCCAP

PRIVATE PAY

CHILD CARE AWARE