Copy of QCPA Summer Camp Registration 2021

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* 1. Camper's Name

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* 2. Desired Camp Sessions (Choose All That Apply)

Camp South America (June 21st-July 9th)

Camp Europe (July 19th-August 6th)

Camp Africa (August 16th-August 27th)

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* 3. Date of Birth

DOB

Date

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* 4. Grade for 2021-2022 School Year

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* 5. Parent Name

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* 6. Email Address

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* 7. Primary Contact Number

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* 8. Address

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* 9. T-Shirt Size

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* 10. Emergency Contact #1

Name

Email Address

Phone Number

Relationship to camper

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* 11. Emergency Contact #2

Name

Email Address

Phone Number

Relationship to camper

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* 12. Approved Pick Up Individuals (ID Cards for these individuals must be on file)

Name & Relationship to camper

Name & Relationship to camper

Name & Relationship to camper

Name & Relationship to camper

Name & Relationship to camper

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* 13. Allergies or Medical Conditions (If medication is needed, please provide medication information)

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* 14. I understand that once I register I will be billed for my $100 registration fee via The Quinn Center's online payment portal. I understand that my spot is not secured until I submit my $100 payment.

Yes

No