Camp ASB Registration Form

Registration Form 2022-2023

In the event of an emergency, or your child becomes ill at Camp ASB, it is imperative we have up to date information so that you can be notified and arrangements can be made. You will be called first, and only if you cannot be reached will other steps be taken.

Student Information

Please register each student individually.

Student full name: *

Answer required for "Student full name: "

Grade for 2023-2024 school year*

Answer required for "Grade for 2023-2024 school year"

Home Address*

Answer required for "Home Address"

Allergies, Medical, or Special Needs

Answer required for "Allergies, Medical, or Special Needs"

Student's Physician & Phone Number*

Answer required for "Student's Physician & Phone Number"

Student's Dentist/Orthodontist & Phone Number*

Answer required for "Student's Dentist/Orthodontist & Phone Number"

Parent 1 / Guardian Information

Full Name*

Answer required for "Full Name"

Email Address*

Answer required for "Email Address"

Phone Number*

Number Required

Alternate Phone Number

Number Required

Parent 2 / Guardian Information

Full Name

Answer required for "Full Name"

Email Address

Answer required for "Email Address"

Phone Number

Number Required

Alternate Phone Number

Number Required

Authorizations

Additional people who may pick up your child:*

Answer required for "Additional people who may pick up your child:"

I hereby give permission for my child to receive the following at Extended Care when necessary:*

Answer required for "I hereby give permission for my child to receive the following at Extended Care when necessary:"

Benadryl

Ibuprofen

Tylenol

Family provided medicine with instructions

None

The staff of Assumption-St. Bridget's Camp ASB will take the steps indicated in case of injury or illness to my child.*

Answer required for "The staff of Assumption-St. Bridget's Camp ASB will take the steps indicated in case of injury or illness to my child."

I hereby authorize

Emergency Contacts

Used in case you cannot be reached. These contacts may also be called if Camp ASB is closed and a parent/guardian has yet to pick up your child(ren).

Emergency Contact 1 Full Name*

Answer required for "Emergency Contact 1 Full Name"

Emergency Contact 1 Phone Number*

Answer required for "Emergency Contact 1 Phone Number"

Emergency Contact 2 Full Name*

Answer required for "Emergency Contact 2 Full Name"

Emergency Contact 2 Phone Number *

Number Required

Rates & Billing Information

Registration fee: $55 (1 paid per family)
Hourly- $12 an hour
Prepaid week- $400 (breaks down to about $9 an hour, if used full time)
Prepaid session, 1 or 2- $1000 (breaks down to about $7.50 an hour, if used full time)
Prepaid both sessions- $1750, registration fee will be waived (breaks down about $6.50 an hour, if used full time)

Please indicate which payment option you are selecting for Camp ASB 2022. Charges for Camp ASB will be added to FACTS after confirmation with each family. If prepaying for weeks or sessions, those charges will be added the Friday before the prepaid week.

Answer required for "Please indicate which payment option you are selecting for Camp ASB 2022. Charges for Camp ASB will be added to FACTS after confirmation with each family. If prepaying for weeks or sessions, those charges will be added the Friday before the prepaid week."

Hourly drop-in, $12 an hour

Weekly prepayment, $400 per week

Session 1 prepayment, $1000

Session 2 prepayment, $1000

Camp ASB fulltime prepayment, both sessions, $1750

If you are choosing to prepay for specific weeks of Camp ASB, please indicate which week(s) below:n

Answer required for "If you are choosing to prepay for specific weeks of Camp ASB, please indicate which week(s) below:n"

Session 1, week 1

Session 1, week 2

Session 1, week 3

Session 2, week 1

Session 2, week 2

Session 2, week 3

Parent/Guardian Signature: *

Answer required for "Parent/Guardian Signature: "

Please fix the highlighted areas below before submitting.

Camp ASB Registration Form

Registration Form 2022-2023