Day Camp
Registration
Good Earth Learning Center
Child"s Information
First name
Last name
M.I.
Street address
Street address line 2
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Male or female?
Female
Male
Age
Date of birth
-
Month
-
Day
Year
Date Picker Icon
Week(s) my child will attend camp
Hours of child care required (school hours are 8:00 am to 3:30 pm)
8-3:30
before care
after care
Days of the week will attend
Monday
Tuesday
Wednesday
Thursday
Friday
Parent"s Information
Parent"s/Guardian"s name
Phone number
Place of work
Email address
Emergency Contact 1
In the event of an emergency, please contact:
First name
Last name
Primary phone number
Secondary phone number
Emergency Contact 2
In the event of an emergency, please contact:
First name
Last name
Primary phone number
Secondary phone number
Other people authorized to pick up your child from daycamp
First name
Last name
First name
Last name
Medical information
Doctor
Doctor"s phone number
Dentist
Dentist"s phone number
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
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