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Registration Form

Camper
Camper first name *
Camper last name *
Date of birth *
Gender

Program Choices

Select the weeks that you would like to send your camper to Kim's Kids.

Base program cost from your selection: $2615

* Please note that Kims Kid's will be closed on July 4 and July 5. There is a reduced rate for this week.


Early and late bird

Parent or Guardian

Aaron McMickle

aaronspins@gmail.com

Cell phone * (000-000-0000)
Alternate phone (000-000-0000)
Relationship *
Address *
City *
State *
Zip *

Emergency Contact

A second parent or another trusted adult.

First name *
Last name *
Relationship *
Phone * (000-000-0000)
Alternate phone (000-000-0000)
Email *

Additional Emergency Contact (Optional)

Full Name
Phone (000-000-0000)
Relationship

Pediatrician
Full Name *
Phone * (000-000-0000)
Child's Health Issues *
Please enter 'None' if there are no issues.

Consent and Permission
Digital signature *
Please type your name above. You agree that by typing your name, you are electronically signing this document.