Eco Art Summer Camp Registration

2019 Fruiggie Eco Art Summer Camp Program Registration

Child’s Information

* Indicates required field

Child Name #1 *

First

Last

Gender *

Male Female

Birth Date *

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Child’s Home Phone *

Child Name #2 *

First

Last

Gender *

Male Female

Birth Date *

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Child’s Home Phone *

Child Name #3 *

First

Last

Gender *

Male Female

Birth Date *

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Child’s Home Phone *

Medical

Please list any medical problems, including any requiring maintenance medication and treatment (i.e. Diabetic, Asthma, Seizures). *

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? *

Yes No

If yes, please specify. *

Is your child allergic to any type of food or medication? *

Yes No

If yes, please specify. *

Does your child require a special diet? *

Yes No

If yes, please specify *

Parents/Guardian Contact Information

Parent/Guardian #1

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Work Phone *

Cell Phone *

Email *

Occupation *

Employer *

Parent/Guardian #2

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Work Phone *

Cell Phone *

Email *

Occupation *

Employer *

Emergency Contact Information

Emergency Contact #1

Name *

First

Last

Phone Number *

Email *

Relationship to Child *

Please Choose Camp Week(s)

Choose Any *

Week 1: Paper Making & Paper Mache Week 2: Sculpting & Printing Week 3: Ancient Arts & Crafts Week 4: Musical Instruments around the world Week 5: DIY Nature Jewelry, Accessory, and Fashion Designing Week 6: DIY Children Bedroom Decor Week 7: DIY Vegan cooking & Baking Class Week 8: DIY School Supplies

Please choose how you heard about Fruiggie Eco Art Summer Program. *

Please specify below *

Comment *