2019 Summer Camp Registration

Please complete a registration form for EACH child attending our Summer Camp Program.

Camper's Name *
Camper's Name
Camper's Date of Birth *
Camper's Date of Birth
What grade will the camper be entering next school year.
All sizes are children size.
Parent's or Guardian's Name *
Parent's or Guardian's Name
Home Phone
Home Phone
Cell Phone *
Cell Phone
Primary Address *
Primary Address
By Phone or By Email
Planned Drop-off Time
Planned Drop-off Time
Planned Pick-up Time
Planned Pick-up Time
I give my consent for my child to be transported and supervised by Southlake Tutoring Academy employees: *
Click all that apply.
I give consent for my child to participate in the following Water activities: *
If yes, you will be required to fill out an emergency allergy plan at the office and supply Southlake Tutoring Academy with any medication.
Emergency Contact #1 *
Emergency Contact #1
Emergency Contact #1 Phone Number *
Emergency Contact #1 Phone Number
Emergency Contact #2 *
Emergency Contact #2
Emergency Contact #2 Phone Number *
Emergency Contact #2 Phone Number
In case of Emergency
Physician's Phone Number *
Physician's Phone Number