Total Impact Summer Camp 2023

Total Impact Summer Camp Registration

All campers must submit a Summer Day Camp registration form with health and emergency contact information. A non-refundable $50 registration fee is due by May 31. This fee will be applied to tuition upon your child’s attendance. A form must be filled out for each child. (* Required field)

Camper Name *

Parent Name *

Street Address *

City *

City

State *

Please provide a valid state.

Zip Code*

Zip code .

Parent Phone Number *

Parent Phone Number (Other)

Parent email address *

Camper Birthdate *

Grade entering in the fall *

Start date *

End date *

Days Attending *
Monday
Tuesday
Wednesday
Thursday
Friday

All campers will get a camp t-shirt.
Please choose camper's shirt size *

Please select a valid Size.

Is camper enrolled at WCA for the 2022-2023 school year? *

Please provide a valid answer.

What church, if any, do you attend regularly?

Zip code .

Special Health Concerns: (allergies, medications, etc.) *

Primary Care Information

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Insurance Information

Insurance Provider *

Insurance Policy No *

Insurance Phone *

Subscriber's Name *

Emergency Contact Information

Please list the names of any and all possible persons to whom the ELC is allowed to release your child, if you are not available. Contacts MUST PROVIDE A PICTURE ID in order to pick up your child. By submitting this information, you give us the permission to share health information about your child with the people listed as emergency contacts.

Contact 01

Name *

Phone Number *

Relationship to Child *

Contact 02

Name *

Phone Number *

Relationship to Child *

Contact 03

Name *

Phone Number *

Relationship to Child *

By typing your name and date for the following statements you are giving your legal consent:

I hereby give permission to Total Impact Summer Camp to secure emergency medical and/or dental treatment and to provide emergency transportation for the above named child while in care.

I give permission for the image of my child to be taken in photograph or video, and to be used by Total Impact Summer Camp.

Signature *

Date *