Summer Camp Registration

To enroll your child in Raphael Academy’s summer camp please complete all sections of this registration form. Registration is processed on a first come, first-serve basis.

Child's basic information

Child's name*

First Middle Last

Date of birth*

Age*

Gender*

Residential address*

Street Address City State ZIP Code

Mailing address, if different from residential address

Street Address City State ZIP Code

Phone*

Alternate phone

Current school/program*

Address*

Street Address City State ZIP Code

Grades attended*

Please attach a copy of your child’s current IEP.*

Max. file size: 50 MB.

Parent/Guardian Contact Information

Parent/Guardian Name*

First Last

Relationship to child*

Address, if different from child's

Street Address City State ZIP Code

Home phone*

Mobile phone*

Work/alternate phone

Email*

Occupation

Location of work

I have another parent/guardian to add*

Yes
No

Parent/Guardian 2 Name*

First Last

Relationship to child*

Address, if different from child's

Street Address City State ZIP Code

Home phone*

Mobile phone*

Work/alternate phone

Email*

Occupation

Location of work

Emergency Contact

Emergency Contact Name*

First Last

Relationship to child*

Address*

Street Address City State ZIP Code

Home Phone*

Mobile Phone*

Work/Alternate Phone

Email*

Occupation

Location of work

Summer Camp Registration

Step 1 of 4

Child's basic information

Parent/Guardian Contact Information

Emergency Contact

Student Profile

Medical Needs

Language & Communication

Likes & Dislikes

Application Fee

Signatures