Harns Marsh Elementary Dawn to Dusk Get into the Summer Spirit! Where: 1800 Unice Avenue North Lehigh Acres, FL What: (9 week) Summer Camp Program For Students Grades K-5th When: June 8th -August 7th Time: 7am -6pm (Monday- Friday) FOOD: Lunch and Snack will be provided. *Please note breakfast will not be served PRICE: $35 registration fee per family $75 per week for the first child $65 for each additional sibling Fun Activities Include: Arts and Crafts, Computer Classes, Cooking, Field Trips, Science Activities, Sport Activities, Water Games, Guest Speakers. If you have any questions please call and contact Ms. Dali Cruz at 239-690-1249. Harns Marsh Elementary Dawn to Dusk Summer Camp 2015 Registration Form Registration Fee: $35 per family (Non-Refundable) CHECK ( ) or CASH ( ) only First Child’s Last Name: _____________________________ Birth Date __________________ First Name:_____________________________________ Gender:_______________ Second Child’s Last Name: __________________________ Birth Date:__________________ Grade: _________________ First Name:_____________________________________ Gender: _______________ Third Child’s Last Name: ____________________________ Birth Date: __________________ Grade: _________________ First Name:_____________________________________ Gender: _______________ Grade:_________________ Mother’s/Guardian’s Name __________________________________________________________________________ Home Address _____________________________________________________________________________________ Street Home Phone ( City Zip Code ) _____________ Work ( ) ________________ Cell ( ) ________________ Father’s/Guardian’s Name ___________________________________________________________________________ Home Address _____________________________________________________________________________________ Street Home Phone ( City ) _______________ Work ( Zip Code ) ________________ Cell ( ) __________________ Custody Restrictions ( ) yes ( ) no Please provide custody papers Authorized Persons Permitted to Remove Child (ren) from Program Other than Parents/Guardian: __________________________________________________________________________________________________ Name Phone Relationship __________________________________________________________________________________________________ Name Phone Relationship ___________________________________________________________________________________________________ Name Phone Relationship Special Instructions: (allergies, medications, etc.)___________________________________________________________ ___________________________________________________________________________________________________ I have read the Dawn to Dusk brochure and understand the program rules and my responsibilities toward fees, payments, refunds, etc. Parent Signature_________________________________________ Date __________ *All fees must be prepaid Friday morning or afternoon for the following week. 03/15