Summer Day Camp Registration - Lighthouse Baptist Academy

Child's Information

Child's Name*

Address*

Street Address Address Line 2 City State ZIP Code

Birthdate*

Phone*

Grade Entering in August*

T-shirt Size*

Does the child have any physical limitations?*

Yes
No

Please give a detailed explanation of these limitations.

Parents' Information

Father's Name*

Father's Cell Phone*

Father's Work Phone*

Father's Employer*

Mother's Name*

Mother's Cell Phone*

Mother's Work Phone*

Mother's Employer*

Primary Email*

Secondary Email

With whom does the child live?*

Both Parents
Father
Mother

Emergency Contacts

Please list 2 emergency contacts for your child. These should be responsible adults whom we may call in the event that a parent cannot be reached.

Contact 1*

Relation*

Phone*

Contact 2*

Relation*

Phone*

Day Camp Information

Please select the weeks your child will be attending.*

The weekly cost of $110 will be due at the beginning of that week on Monday.

Authorized Pick-up List

Please list any adults other than the father or mother who are approved to pick up your child.

Name	Relation	Phone

Will your child need Before or After Care?*

No
Before Care - ($45/week)
After Care - ($45/week)
Both - ($60/week)

Terms

I am enrolling my child in the Summer Day Camp program at Lighthouse Baptist Academy, and I agree with the following:

I understand that the $50 registration fee and the $100 Activity Fee are both due before my child can attend the first day of summer day camp. I am also aware that this fee is non-refundable.
I understand that the weekly fee is to be paid on Monday. If the fee is not paid by 6:00 p.m. on Monday, a late fee of $15 will be added to my account. My child will not be able to attend camp until my account is paid in full.
I understand that if one check is returned due to insufficient funds, my account will be placed on a "cash only" basis, and I will be charged an insufficient funds fee.
By digitally signing this enrollment contract for the summer, I agree to accept the rules and regulations of the summer day camp program and the payment of all fees listed above.
I understand that the Lighthouse Baptist Academy Summer Day Camp reserves the right to terminate my child's enrollment at any time necessary without refund of the registration and activity fees.

In making application for my child, I desire to have him/her complete the summer day camp program at Lighthouse Baptist Academy. It is also my understanding that the policy of Lighthouse Baptist Academy is to make no refunds or transfers on registration fees or activity fees. I also give permission for my child to take part in all activities of Summer Day Camp including the provided transportation to and from activities. I further agree to indemnify and hold Lighthouse Baptist Church and Academy or any of its agents harmless for any and all liability that may result from my child attending or participating in all activities of Summer Day Camp.

Signature of Parent / Guardian financially responsible for child

Summer Day Camp Registration and Activity Fees

Product Name

Total Due Today

$50 Registration Fee + $100 Activity Fee + CC Processing Fee =

$0.00

Credit Card

Card Details

Cardholder Name

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