Camp Registration

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CAMP REGISTRATION

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date Of Birth *

Age *

Gender *

Male Female

Home Phone Number *

Other Emergency Number *

Mom's Cellphone Number *

Dad's Cellphone Number *

Best Email *

Mom's Work Number *

Dad's Work Number *

Fees
$35.00 Daily, Monday - Friday, 7:00 am - 6:00 pm
$150.00 Weekly, Monday - Friday, 7:00 am to 6:00 pm
(You will be charged the full weekly rate even if your child is sick, on vacation, or just doesn't want to come, etc)
$50 non-refundable registration fee is required to register your child for either Daily or Weekly Camps.

Week Of: *

Initial to approve the right to charge for late pick ups *

Parents Initial

Initial to acknowledge that payment is due in full on the first day of week *

Parents Initial

Methods Of Payment

We accept cash, check, Venmo (Robin-Cruz-25), Zelle (2142648637) or Cashapp ($caseysplace5156).

We will be closed on 4th of July for Independence Day!!

Additional Information and/or Comments

Allergies To Food *

Allergies To Medications *

Allergies to Laundry Detergent / Fabric Softeners / Chemicals *

Medical Conditions (If Any) For example ADHD, Autism, etc *

List ALL Medications presently taking *

Doctors Name *

Doctors Phone Number *

Medical Insurance *

Policy Number *

Food / Drink my child LOVES *

Food / Drink my child DOES NOT LIKE *

Hobbies or Interests *

Does your child attend Church, if yes, where? *

I Hereby do give/do not give permission for the following for my child

Apply / Give Benadryl as needed *

Yes No

Apply Sunscreen as needed *

Yes No

Authorize to treat an emergency and/or perform CPR *

Yes No

Any other notes or concerns that we should be aware of such as mental health issues, special needs, or certain triggers or any fears like water, dogs, etc. PLEASE BE SPECIFIC!! *

I Hereby authorize my child to be picked up ONLY by the following persons. In case of an emergency and I can not be reached, I authorize Casey's Place to contact

Name *

Phone Number *

Relationship *

In Case Of *

Pick-Up Emergency

Name *

Relationship *

Phone Number *

In Case Of *

Pick-Up Emergency

Name *

Relationship *

Phone Number *

In Case Of *

Pick-Up Emergency

Required Supplies for Summer

Swimming attire-bathing suits (no bikinis). Sunblock, beach towel, water shoes or flip flops, water bottle. Extra set of clothes (we will maintain clothes as needed)**Boys are required to wear shirts with their bathing suits**
Closed toed shoes are to be worn at all times on the farm unless swimming.

If you have any further questions, please feel free to contact us at 972-932-5156 or by email info@caseysplace

Submitter Signature *

Submit

Don't forget to submit the Parental Authorization and release form!

Location

Serving Dallas, Henderson, Kaufman and surrounding counties

What Our Clients Are Saying

Casey’s Place has been so wonderful teaching our kids how to care for animals and being social to peers of the same age in the community. As soon as the kids leave Casey’s they are asking “when are we going back?” Casey’s Place plays a big role in the growth of our kids!

David Asbill
Administrative Director
Kaufman County Children's Emergency Shelter

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