www.caseysplace.org
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Free 2B Me Summer Camp
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Registration Summer Camp
Parental Authorization and Release Form
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Registration Riding School
Parental Authorization and Release Form
CAMP REGISTRATION
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Date Of Birth
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Age
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Gender
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Male
Female
Home Phone Number
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Other Emergency Number
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Mom's Cellphone Number
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Dad's Cellphone Number
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Best Email
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Mom's Work Number
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Dad's Work Number
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Fees
$30.00 Daily, Monday - Friday, 7:00 am - 6:00 pm
$125.00 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)
$50 non-refundable registration fee is required to register your child for either Daily or Weekly Camps.
Week Of:
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Initial to approve the right to charge for late pick ups
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Parents Initial
Initial to acknowledge that payment is due in full on the first day of week
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Parents Initial
Methods Of Payment
We accept cash, check, Venmo (Robin-Cruz-25)
, Zelle (2142648637) or Cashapp ($caseysplace5156).
We will be closed on 4th of July for Independence Day!!
Additional Information and/or Comments
Allergies To Food
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Allergies To Medication
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Allergies to Laundry Detergent / Fabric Softeners / Chemicals
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Medical Conditions (If Any)
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Medications Presently Taking
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Doctors Name
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Doctors Phone Number
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Medical Insurance
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Policy Number
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Food / Drink my child LOVES
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Food / Drink my child DOES NOT LIKE
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Hobbies or Interests
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Does your child attend Church, if yes, where?
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I Hereby do give/do not give permission for the following for my child
Apply / Give Benadryl as needed
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Yes
No
Apply Sunscreen as needed
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Yes
No
Authorize to treat an emergency and/or perform CPR
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Yes
No
Any other notes or concerns that we should be aware of
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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
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Relationship
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In Case Of
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Pick-Up
Emergency
Name
*
Relationship
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Phone Number
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In Case Of
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Pick-Up
Emergency
Name
*
Relationship
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Phone Number
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In Case Of
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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 caseysplace@embarqmail.com
Submitter Signature
*
Submit
Don't forget to submit the Parental Authorization and release form!
