Summer Camp Registration Form Please enable JavaScript in your browser to complete this form.Parent's Name(s) *Phone *Email *Date *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHow many kids are attending? *Child #1 Name *FirstLastWhat is the childs age? *Summer Camp payment is for the Week of *May 30- June 1June 6-8June 13-15June 20 - 22June 27 - 29 July 4 - 6July 11 - 13July 18 - 20July 25 - 27The children will have opportunities to explore through movement, music, art and most importantly MUD! Child #2 Name *FirstLastWhat is the childs age? *Summer Camp payment is for the Week of May 30- June 1June 6-8June 13-15June 20 - 22June 27 - 29 July 4 - 6July 11 - 13July 18 - 20July 25 - 27The children will have opportunities to explore through movement, music, art and most importantly MUD! Child #3 Name *FirstLastWhat is the childs age? *Summer Camp payment is for the Week of *May 30 - June 1June 6 - 8June 13 - 15June 20 - 22June 27 - 29 July 4 -6July 11 - 13July 18 - 20July 25 -27The children will have opportunities to explore through movement, music, art and most importantly MUD! Child #4 Name *FirstLastWhat is the childs age? *Summer Camp payment is for the Week of *May 30 - June 1June 6 - 8June 13 - 15June 20 - 22June 27 - 29 July 4 -6July 11 - 13July 18 - 20July 25 -27The children will have opportunities to explore through movement, music, art and most importantly MUD! Name of Signee *Signature *Clear SignatureDate *Please list any allergies or information that you feel Dirt Learning needs to know about your child.Payment InformationHow will you pay for your Registation Fee *Pay at time of Form SubmissionPay Via VenmoI have already paid my Registration Fee for 2023 Summer CampPayment for Registration Fee *Pay through Site - $ 55.00By checking this box you are giving permission to Dirt Learning to take payment for registration through square via site. *Registration fee will be paid thru Venmo - $55By checking this box I am stating payment will be made for registration via Venmo Name: @dirtlearning last 4 of phone number: 5227 How will you pay for Summer Camp? *Pay via website at time of submissionPay Via VenmoSummer Camp TotalPlease list the amount paying for one or multiple children. If you are paying for multiple sessions, please ensure to list all weeks above. One Child - $125.00 Per Session, Past | Upcoming Student Weekly Registration $85.00. Registration fee $55 is paid once for the summer. by checking this box I am commiting payment via venmoPlease send payments for venmo to the information listed. Venmo Name: @dirtlearning last 4 of phone number: 5227SquareCardName on CardTotal$ 0.00Submit
