Fall Break Camp

Fall Break Registration Form

Thank you for your interest. Please complete this registration form and someone from our staff will call you to discuss our fees and Hours of operation.

Your card will not be charged until you actually register your child(ren) in person and determine their start date.

Primary Parent Name

First Name

Last Name

Parent Email Address

Cell Phone

(###)

###

####

Child Name

First Name

Last Name

Child Name #2

If needed

First Name

Last Name

Child(s) Address

Address of Primary Parent

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child Date of Birth

1st Child

YYYY

Child 2 Date of Birth

2nd Child

YYYY

Current Grade(s)

Work Phone

(###)

###

####

Father Name

If needed

Father Name

First Name

Last Name

Father Cell

(###)

###

####

Father Address

If different than 1st name

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Emergency Contact Name

First Name

Last Name

Emergency Contact Cell

(###)

###

####

Relationship To Child

Any Known Allergies

T-Shirt Size(s)

Child XS- Adult Large

Payment Information

Name on Card

First Name

Last Name

Card Type

Visa, MasterCard, etc.,

Card Number

xxxx-xxxx-xxxx-xxxx

Expiration Date

xx/xx

CVV Code

xxx On back of your card

Permissions

Check all options

I the parent/guardian give my son/daughter permission to participate in activities.

I the parent/guardian also grant New Faith permission to take photos of that may be used for media/website.

I agree to having my card processed electronically via this website, having read the privacy policy.

Start Date of Care

YYYY