Register

To register your child for the program for Summer 2015,
 please print the form below, fill in the information, and mail it to: 
Ashley Gullett, 42 Commonwealth Ave., Gloucester, MA 01930   
OR you can call, text, or email me your address, and I will mail the forms to you.

Summer Adventure Club

42 Commonwealth Ave.

Gloucester, MA 01930

978-325-0956

2015 Registration Form

Date: ____________

Child’s name: __________________________________________________   Age______ 

DOB _________

Week/s Attending (Circle)    1          2          3          4          5          6          7          8         

Parent or Guardian’s Name/s: 

_____________________________________________________________

Emergency Contact Information: 

_______________________________________________________________

Parent/Guardian Contact Information:

Home _____________________________________

Cell      _____________________________________

Work   _____________________________________

Email   _____________________________________

Address __________________________________________________

__________________________________________________________

Person other than parent responsible for picking child up from camp:

Name: _______________________________________________________

His or Her Contact Info: ________________________________________

Are there any allergies or other medical information I should know about your child? 

______________________________________________________________

______________________________________________________________

______________________________________________________________

_______________________________________________________________

Are there any learning disabilities or special educational needs that I should know about your child?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Do you give your permission and consent for your child to be photographed while participating in the Summer Adventure Club Activities or Field Trips?             YES                 NO

May we share your child’s photo on the Summer Adventure Club blog or Facebook page? 

YES        NO

Please sign below that you give your consent for your child to participate in all the activities and field trips planned during the week your child attends the Summer Adventure Club and that you understand the code of conduct and support the mission of the Summer Adventure Club.

Parent Signature: 

__________________________________________________

Date: __________