Summer Camp

AMBASSADOR CHRISTIAN ACADEMY

SUMMER CAMP APPLICATION

700 Main Street

Toms River, New Jersey 08753

Phone: 732-341-0860

Fax: 732-349-0731

www.ambassadorchristian.org

Camper’s Full Name____________________________________________________________________________

Age_________ (as of 6/29/2010) Date of Birth________/_________/________ Gender _____M _____F

Entering Grade_________ in September 2010 at__________________________________________________School

Home Phone _________________________________________

Home Street Address ___________________________________________________________________________

City__________________________________________________ State_____________ Zip__________________

Parent/Guardian’s Full Name____________________________________________________________________

Parent/Guardian’s Work Phone______________________________ Cell _______________________________

Parent/Guardian A’s E-mail address________________________________________________________________

Fax___________________________________________________

Sibling(s) enrolled in Ambassador Christian Academy Summer Camp 2009:

______________________________________________________________________________________

Check week(s) camper will attend PROGRAM FEES

____Week 1 * June 28 – July 2 $200.00 weekly per camper

____Week 2 * July 5 – July 9 $1,300.00 full summer per camper

____Week 3 * July 12 – July 16

____Week 4 * July 19 – July 23 Some trips additional cost

____Week 5 * July 26 – July 30 Camp Tuition May Be Tax Deductible

____Week 6 * August 2 – August 6

____Week 7 * August 9 – August 13

Medical Release: In the event that I/we as parents/guardians cannot be reached, I/we hereby give permission to Ambassador Christian Academy Summer Camp staff to seek medical attention for my/our child.

____ ____________________________________ _____________________

Parent/Guardian Signature Date

Password that MUST be used to pick up your child from camp __ __ __ __ __ __

(Six letters or less)

Person(s) including parents/guardians authorized to pick up child at the end of camp day/ extended care program:

Name_______________________________ Phone______________________Relationship___________________

NOTE: If any person other than those listed above is to pick up a camper, a written note must be sent that morning with the child or faxed to the office – NO exceptions!

Tee-Shirt Size (check one) Child’s Current Swimming Level

___ Youth Small (Size 6-8) ___ first time and/or needs swimmies, etc.

___ Youth Medium (Size 10-12) ___ beginner

___ Youth Large (Size 14-16) ___ has had some lessons

___ Adult Small ___ intermediate

___ Adult Medium ___ experienced

___ Adult Large

___ Adult X-Large

APPLICATION CHECK LIST

PLEASE ATTACH EACH OF THE FOLLOWING TO THIS APPLICATION:

___ A $25.00 Non-Refundable Registration Fee

Please make checks payable to Ambassador Christian Academy

___ A photocopy of the front and back of the family’s health insurance card

___ A fully completed emergency/health form

___ An up-to-date copy of the child’s immunization records

___ ACA Summer Camp discipline policy signed by parent and camper

The whole earth is filled with the glory of God.

Isaiah 6:3

Office Use Only

Amt Rec’d_________________Check # __________________ Date Rec’d:________________

Ambassador Christian Academy

700 Main st