Summer Program Registration Form

Child Information

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade (as of next school year)

Gender

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Which session(s) will your child be attending (you can click more than one)?

Which days will your child attend camp during the above session(s) (it’s only open Tuesday, Wednesday, and Thursday for each session)?

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Does the child have any particular interests or things they would like to do at camp?

Informed Consent and Acknowledgement

I hereby give my approval for my child's participation in any and all activities prepared by Molly Dickerson during the selected session(s).

Details and Information

The links for the zoom meeting each day will be sent out to the email you have provided. A lunch will be expected to be prepared by a parent, guardian, sibling, or other person in the household, so as not to take any time away from the activities planned. This costs $10 per day, or $30 for a whole session. Payment information will be emailed. If there are any further questions, don't hesitate to contact me at (781) 434-9536 or molly.r.dickerson@gmail.com.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Molly’s Virtual Summer Program Registration