Camper Name_ ____________________________________________________________

 Male Female                                   Birthdate_______________ Age During Camp________

Address___________________________________________________________ City______________________________________State_ ______ Zip___________

Email address___________________________________________________ This email address belongs to:  camper  parent/guardian (For camp use only. Never shared or sold.)

Camper’s School_____________________________________________________________________________________________________Grade next Fall________

Parent’s and/or Guardian’s Name______________________________________________________

Home Phone_____________________________________________

Mobile Phone_ ___________________________________________

Work Phone_____________________________________________

Child's Allergies:_______________________________________________________________________

Additional info. helful to our staff for your child's needs: ______________________________________________________________________________________________________________________

In case there’s an emergency and parent/guardian cannot be reached, please notify:

Name________________________________________________Work Phone____________________________ Home Phone________________________________

Address___________________________________________________________ City______________________________________State_ ______ Zip___________

How did you hear about Camp Giggles The Clown? 

 Friend’s Referral (please list friend’s name) ________________________________________________

Statement of Parent or Guardian: I do hereby grant permission for my son/daughter/ward to attend Camp Giggles The Clown during the camp sessions listed below: I indicated herein. I agree to assume the responsibility for the financial obligations to the camp.

Parent or Guardian Signature________________________________________________________________________ Date___________________________________

A $20 registration fee is due upon registration of each child and is non-refundable.

I wish  for my child to attend:: :date age group tuition

Week 1 Cooking Camp  6/16-6/20 ages 4-10 9am-12pm  $50.00 _____

Week 1 Cooking Camp  6/16-6/20 ages 11-14 1pm-4pm  $50.00 _____

Week 2 Craft/Pottery Camp 6/23-6/27 ages 4-10 9am-12pm $50.00 ______

Week 2 Craft/Pottery Camp 6/23-6/27 ages 11-14  1pm-4pm $50.00 ______

Week 3 Pet Care/Jungle Camp 7/7-7/11 ages 4-10 9am-12pm $50.00 _____

Week 3 Pet Care/Jungle Camp 7/7-7/11 ages 11-14 1pm-4pm $50.00 _____

Week 4 Circus Camp 7/14-7/18 ages 4-10  9am-12pm  $50.00_____

Week 4 Circus Camp 7/14-7/18 ages 11-14 1pm-4pm  $50.00_____

Week 5 Water Fun/Sports Camp 7/21-7/25 ages 4-10 9am-12pm $50.00_____

Week 5 Water Fun/Sports Camp 7/21-7/25 ages 11-14 1pm-4pm $50.00_____

Week 6 Science/Nature Camp 7/28-8/1 ages 4-10 9am-12pm $50.00______

Week 6 Science/Nature Camp 7/28-8/1 ages 11-14 1pm-4pm $50.00_____

Week 7 The Great Outdoors Camp 8/4-8/8 ages 4-10 9am-12pm $50.00_____

Week 7 The Great Outdoors Camp 8/4-8/8 ages 11-14 1pm-4pm $50.00_____

Week 8 Drama & Theatre Camp  8/11-8/15 ages 4-10 9am-12pm $50.00_____

Week 8 Drama & Theatre Camp 8/11-8/15 ages 11-14 1pm-4pm $50.00_____

Week 9 Kids Choice  Camp 8/18-8/22 ages 4-10 9am-12pm $50.00_____

Week 9 Kids Choice Camp 8/18-8/22 ages 11-14 1pm-4pm $50.00_____

Registration Fee: $20.00 per child__XXX___

Weeks 1-9 Summer Camp Non-Resident Fee                $375.00_______

Weeks 1-9 Summer Camp Non-resident fee 2nd child   $350.00_______

Weeks 1-9 Summer Camp resident fee                          $350.00_______

Weeks 1-0 Summer Camp resident fee 2nd child           $325.00_______

*All fees include snack, supplies and materials for all camps.

Total Enclosed:                                                                $_______________

*Make Checks Payable to L.Kozak dba Giggles the Clown.

Signature:_____________________________________________________

Payment Plan:  50% down & balance divided by 9 weeks due and payable each Monday of Camp: Due for registration                                $__________50%

Balance                                                                               $__________

Due each Monday                                                               $__________

Plus $30.00 Payment Plan fee                                             $__________

Signature:_____________________________________________________

 MEDICAL RELEASE FORM PRINT SIGN AND RETURN WITH REGISTATION  & PAYMENT.

Medical Release. I, in my own behalf and on behalf of Minor, acknowledge and agree that such participation subjects Minor

to possibility of physical illness or injury (minimal, serious, catastrophic and/ or death) and that I, in my own behalf and on

behalf of Minor, acknowledge Minor is assuming the risk of such illness or injury by participating in the Camp, Giggles The Clown.. In the event of

such illness or injury, I authorize Lynda Kozak DBA Giggles The Clown/Arellanes Farms  to obtain necessary medical treatment of Minor and hereby, in my own

behalf and on behalf of Minor, release and hold harmless Releasees in the exercises of this authority. I further acknowledge

and understand that I will be responsible for any and all medical and related bills that may be incurred on behalf of Minor for

any illness or injury that Minor may sustain and release Lynda Kozak/Albert Arellanes DBA Giggles The Clown from all financial resposibility relating to injury, loss, death or any other act of God.

Signature________________________

Date_____________________________