ArchiVenture 2019 Registration

A separate entry (registration) is required for each child registered.

Camp schedule: July 22-26, 2019 from 8am - 5pm. Before and after care is not available at this time.

Cost: DISCOUNTED to $100 per child which includes a $25 non-refundable registration fee.

To pay by credit card, click HERE or use the link included in the confirmation email you will receive following submission of the registration form. Cashier’s checks and money orders (ONLY) will be accepted on the participant’s first day of camp. Make cashier’s checks and money orders payable to the Little Phoenixes Foundation.

No cash or personal checks will be accepted.

Registration fee waivers and limited camp scholarships are available. Email Info@LittlePhoenixes.org for eligibility requirements and to apply.

Participant Information

Child's Name:

First Name

Last Name

Birthdate:

YYYY

Ethnicity

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ward or County:

If a resident of the District of Columbia, indicate Ward #. If a resident of Maryland, indicate County.

School:

Grade:

Any allergies:

Yes

If so, list allergies here:

Please note whether the allergy is an ingested or a contact allergy.

Medical Information

Does your child need to take prescription or over-the-counter medications during camp hours?

Yes

If so, list medications here:

List any medications your child will be taking at home during the duration of the camp AND/OR any medication your child will need to take during the camp hours.

Is participant covered under health Insurance?

Yes

Insurance provider:

Subscriber's name:

Group #

Policy #

Participant's relationship to subscriber:

Subscriber D.O.B.

YYYY

Parent / Guardian Information

Parents Name:

First Name

Last Name

Email Address:

Work Phone Number:

(###)

###

####

Cell Phone Number:

(###)

###

####

Secondary Parent / Guardian Name:

First Name

Last Name

Work Phone Number:

(###)

###

####

Cell Phone Number:

(###)

###

####

Number of People in Household:

Language Spoken in Home:

Income Level:

In Case of Emergency

Name of local friend or relative (not living at same address):

First Name

Last Name

Relationship to participant:

Cell Phone Number:

(###)

###

####

Work Phone Number:

(###)

###

####

T-Shirt Size:

Pick Up Permissions

The Following persons are permitted to pick up my child:

Name 1:

First Name

Last Name

Name 2:

First Name

Last Name

Name 3:

First Name

Last Name

How did you hear about ArchiVenture?

If "Other", indicate how you heard about ArchiVenture: