Life Skills Prep Camp 2023 | Powerful Education Solutions

Life Skills Prep Camp 2023 Registration

Child's Full Name

Street Address

City

Region/State/Province

Postal / Zip code

Age

Date of Birth

Current Grade

Other Programs Currently Attending

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Emergency Contacts

Additional contacts if primary parent/guardian cannot be reached. At least one emergency contact must be listed.

Emergency Contact Full Name

Phone

Emergency Contact #2 Full Name

Phone

Medical Information

Please list any allergies and/or food intolerances here and actions to be taken if emergency occurs.

Please list any physical or developmental problems that may need special accomodations during camp. (i.e. Sensory issues, anger management, etc)

If yes above, click here to download medical form. Upload completed form below.

If answered YES above, please click here to download medical form. Please e-mail completed form to office@loristephensllc.com prior to camp dates.

Notes

Please add any additional requests and notes here.

How did you hear about us?

Payment

Please choose the session you would like to register for. We accept PayPal and all major credit cards. If you do not have a PayPal account or wish to pay with a card, choose "Pay with Debit or Credit."

Select an item ($)

Option 3 July 10-21 - $700

Life Skills Prep Camp 2023 Registration

Parent/Guardian Information

Emergency Contacts

Medical Information

Notes

How did you hear about us?

Payment

Contact

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