2012 Online Registration Form for School-Age Summer Camp

There is a non-refundable registration fee per child for all families at the time of registration to hold your child’s spot. This form is for online registration only. After completing this form, you will be directed to pay the registration fee by credit card. Our online registration is only set up to take credit cards. If you would like to pay your registration fee by check or money order, you will need to fill out our mail in registration form and mail it in with your registration payment. Registration will be taken as a first come, first serve basis.

For Maple Heights Summer Camp Program please call the enrollment specialist at 440.260.6001.

Child's First Full Name:		Last Name:
Child's Birth Date:		Child's Age:
Child's Gender:	MF	Child's Race:	Unknown American Indian Multi-Racial Black/African American Other Hispanic White Asian
Child's T-Shirt Size:	--Not Selected-- Child's Small Child's Medium Child's Large Adult's Small Adult's Medium Adult's Large Adult's Extra Large	Grade completed for the 2011/2012 school yr:
Parent's First Full Name:		Last Name:
Parent's First Full Name:		Last Name:
Address:		Address 2:
City:		ZIP:
Email:		Phone:
How did you hear about us:		Choose one Newspaper/Magazine Google/Other Search Engine Facebook Friend or Family Direct Mail Piece Child Care Center Employee Other
Has this child in the past received services from any part of our agency?		YesNo

Click here if you are eligible for a staff discount:

Click here if this child is eligible for the sibling rate

Payment Category: Please Select Payment Category Private Pay County Assistance  

Location: Please Select Location Berea Brook Park Lakewood