Peace Memorial Presbyterian Church
Monday, May 01, 2017
find peace

Summer Camp Online Registration

30 Spaces available for kids completed K-5th grade.
Older Children may serve as volunteers.  
Please complete a separate form for each child you are registering. 

Child's Name: 
Preferred Name: 
Grade Completed:  Birth Date:  Age: 
Parent(s) Name: 
Mailing Address: 
City:   State:   Zip: 
Home Phone: 
Home Email:  
CARE PROVIDER INFORMATION (please provide two people to contact)
Relationship to Child:
Daytime Phone:   Cell Phone:
Relationship to Child:
Daytime Phone:   Cell Phone:
People who may pick up your child:
Does your child have food allergies:
No       Yes     
Medical Concerns:
No       Yes 
T-shirt Size:  YOUTH S   YOUTH M    YOUTH L    YOUTH XL   
                         ADULT S    ADULT M   ADULT L   ADULT XL
Regular Program (9:00 am-2:00 pm) - $30
               Special Interest Activity (choose one):   Music   Art    Drama
Please provide any additional information that may be helpful to the staff of Peace Memorial concerning special circumstances involved with your child: