PAT 2012 Springtime at the Farm Camp Registration Form

　

Child First 　 Child Last
Parent First 　
Parent Last 　
Street 　
City/ST/ZIP 　 City ST      Zip 
Home Phone 　
Mobile Phone 　
Email Address 　
Child Birth Date 　
Child Age 　
Child Shirt Size 　 XS    Small
Medical Conditions 　   Food Allergies:
Emergency Contact 　   Emergency Phone 
　 　 　
　 　 　
　 　 　
I Agree I give permission to Parents As Teachers of Porter County to take immediate action if my child should need immediate medical attention in the case of an emergency.   I understand I must be accessible during camp hours by one of the phone numbers provided. If I am not available I will ensure the emergency contact can be reached if needed.
　 　 　
I Agree I consent to having my child photographed for the purpose of documenting summer camp and for use in publications for the purpose of positive promotion of Parents As Teachers of Porter County and/or Porter County Parks.
　 　 　
I Agree I agree to make immediate payment.

You will receive confirmation of your enrollment upon receipt of this form.  Please note payment must be made at the time of registration. 

ONLY PAYMENT WILL SECURE YOUR SPOT. Once paid on our secure payment site, you will receive immediate confirmation of payment.

PAYMENT CAN BE MADE BY CREDIT CARD OR ELECTRONIC CHECK. Camp information will be emailed to you two weeks prior to the start of camp.  Questions in the meanwhile can be directed to 395-8412 or email to info@patpc.org. 

  

　

ONCE YOU HAVE SUBMITTED THIS FORM YOU WILL BE DIRECTED TO PAYMENT SITE