Name:             ____________________________    M or F    Age  _______    Grade last completed ______

Name (Sibling): ____________________________   M or F   Age     _______    Grade last completed ______

Name (Sibling): ____________________________   M or F   Age      _______     Grade last completed _____

Street:          __________________________________       City, State, Zip:______________________________

How did you hear about us?  (please check one)    ______internet    _____postcard     _____friend

Has your child been to one of our Adventure camps in the past?       Yes      No

If so which adventure ?   ____   Bluebeard's Lost Treasure      
                                    ____   Davy Jones' Locker and the Mermaid Treasure
                                     ___    The Mystery of Fire Island

Which weeks did your child attend?      _____ first week     ____ second week     ___ both weeks

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Mother’s Name/Guardian:_________________________________________

          Mother’s/Guardian Daytime Phone:__________________________________

          Mother’s/Guardian Cell Phone:_____________________________________

Father’s Name/Guardian:__________________________________________

          Father’s/Guardian Daytime Phone:__________________________________

          Father’s/Guardian Cell Phone:______________________________________

If a Guardian, relationship to child is  _________________________________

Names and Phone Number of anyone else authorized to pick up your child:                                                                 These names and phone numbers will also be used in a case of emergency

_________________________________Phone___________________________

_________________________________Phone___________________________

_________________________________Phone___________________________

_________________________________Pone____________________________

Only the people whose names are printed here will be allowed to pick up your child. 

ID maybe required if we do not recognize the person picking up your child.  

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FEES:   $225 per week + $12 per excursion

Extended Day (     )     $40 per week

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Please Circle one:           1 week      2 weeks

Dates (please circle):      July 16-20    July 23-27     July 16-27 (2 weeks)

Please Circle one:           Regular Day  9:00 -3:00       Extended Day 8:30- 5:00

Will there be a sibling?    yes    no      (One sibling can attend for free, circle a regular price below, before June 15)  
                                                            (Receive 30% discount, 2 at regular price deduct 30%, before July 5)

Did you sign up a friend?  yes   no      (circle one of the regular prices below and deduct 30%, before June 15)
                                                          (circle one of the regular prices below and deduct 20% , before July 5)
Name of friend _____________________               

 Please Circle which one you are signing up for:

2  WEEK TOTAL = $474.00                                 TOTAL BEFORE JUNE 15th = $355.00           TOTAL BEFORE JULY 10TH = $399.00

2  WEEK EXTENDED DAY TOTAL = $514.00       TOTAL BEFORE JUNE 15TH = $386.00         TOTAL BEFORE JULY 10TH = $435.00

Only one discount will apply.

PLEASE WRITE TOTAL AMOUNT $_______________                                                                               

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PAYMENT OPTIONS   (please place a check mark next to the one you will be using)

_____   1.  Print the application and send Check/Money Order with application to the main office.

______  2.  Fill out the Visa/Master Card information below and Fax it with application to 619- 795 -2273

______  4.  Fill out the Visa/Master Card information below and mail it with the application to the main office

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Checks /Money Orders made Payable to:  Pirate Camp for Kids   (See below for mailing address)

Check # :________________________      (if paying by check please indicate # for your records and ours.

Credit Card Information (please check one)   _____ Visa   _____MasterCard

Name on Card _____________________________________

Card Number:_______________________________________

Billing Address_______________________________________

City, State, Zip_______________________________________

Verification Code:(3 digits on back)_______________________

Expiration Date: ____________

Signature:_________________________________________

Please call and leave a message at 760-912-1497 or Email us at  info@piratecampforkids.com to let us

know that an application is on its way and we will hold you a spot.

Pirate Camp for Kids

110 West C Street Suite 1717

San Diego, CA 92101

Phone: (760) 912-1497

FAX: (619) 795-2273

Doctors Name:__________________________________________________

If parents cannot be reached who can we contact in the case of emergency

Name _________________________  Phone _____________________ Relation_________________________

Health Insurance Co.:_______________________________________________

Doctors Phone:____________________________________________________

Group #:__________________________________________________________

Child’s Allergies (if any):_____________________________________________

Child’s known food or drug allergies (if any):_____________________________

Current Medication/s (if any):_________________________________________

Chronic Illness (if any):______________________________________________

Is your child allergic to insect bites?___________________________________

If "yes," describe insect and medication needed._________________________

Will it be necessary for your child to receive medication during camp?_______

If you answered "yes", we will send you a separate form to give us directions on how to

dispense your child's medication.

List and describe any medical conditions with which our staff should be aware:

______________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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(Please print) I, _______________________________________ hereby give my consent to Pirate Camp For Kids, who will be caring for my child/children, to arrange for emergency/medical/surgical/dental care and

treatment (including diagnostic procedures) necessary to preserve the health of my child. I acknowledge that I am

responsible for all reasonable charges in connection with any care and treatment rendered.

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If your child requires a certain medication during camp hours please check here ____________

We will send you a form to fill out to give us directions on this.

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. I understand that Pirate Camp For Kids will not assume responsibility for accidents and/or medical or dental expenses received as a result of participation in the camp/s.

. In the event emergency contacts cannot be reached, I hereby grant Pirate Camp For Kids permission to give whatever immediate treatment is necessary and/or take my child to the Hospital Emergency Room.

. I give permission to Pirate Camp For Kids to dispense medication to my child according to the information I provided if my child is receiving regular medication during camp hours.

. I understand that no reduction in the tuition will be made for late arrival or early departure.

. I understand that only 20% of tuition of remaining prorated days will be returned if my child should be dismissed from camp.

. I give Pirate Camp For Kids consent to use the name and/or photograph/video of my

registered child for inclusion in promotional and informational materials. This includes (but is not limited to)

newspaper, television, and brochures. I waive the right to approve such uses and I release Pirate Camp For Kids from any liability.

. No refunds or exchanges will be made once payment has been received.

. Permission is hereby granted for my child to attend all scheduled field trips and off-facility activities.

I HAVE CAREFULLY READ ALL OF THE INFORMATION, POLICES AND PROCEDURES ABOVE AND

 (AND/OR WEBSITE) AND I AGREE TO ALL TERMS AND CONDITIONS.

Parent/Guardian Signature:_______________________________________

Print Name _____________________________________________

Date:____________________

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