Summer Camp Registration Form

PARENT/GUARDIAN NAME(S) *

First

Last

EMAIL *

ADDRESS *

PHONE NUMBER *

ALTERNATE CONTACT

PHONE NUMBER

STUDENT’S NAME | AGE | SUMMER CAMP DURATION | FEE

Separate values with comma

IF ANY OF THE STUDENTS HAVE MEDICAL/SPECIAL NEEDS, PLEASE LIST DETAILS BELOW:

LUNCH OPTION (see menu)

Do you have any food allergies?

If yes, please list applicable food(s)

Would you like to participate in our annual Piccadilly Summer Party? (5% discount applicable)

TOTAL PAYMENT DUE

METHOD OF PAYMENT *

PICK UP: I GIVE PICCADILLY ENTERTAINMENT THE PERMISSION TO RELEASE MY CHILD TO THE FOLLOWING PEOPLE. *

I GIVE PICCADILLY ENTERTAINMENT THE PERMISSION TO RELEASE MY CHILD TO THE FOLLOWING PEOPLE.

NAME | PHONE NUMBER | RELATIONSHIP

Separate values with comma

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