Summer Camp

Child's Name*

First Last

Child Age*

Child Date of Birth*

Parent/Guardian's Name*

First Last

Cell Phone*

Home Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Additional Sibling

Yes
No

Additional Siblings Attending

Second Child's Name*

First Last

Second Child's Date of Birth*

Second Child's Age*

Additonal Sibling

Yes
No

Third Child's Name*

First Last

Date*

Third Child's Age*

Additional Information

Please list any allergy or medical information we may need.

Who is permitted to pick up your child?

These are the only people we will release your child to unless written notice is given.

Which weeks will you be attending?*

Week 1: June 5 - 9
Week 2: June 12 - 16
Week 3: June 19 - 23
Week 4: June 26 - June 30
Week 5: July 10 - 14
Week 6: July 17 - 21
Week 7: July 24 - 28
Before/After Care 7:30am-6:00pm ($25 per child/per week)

Terms and Conditions

I fully understand that there are inherent risks associated with roller skating and I accept those risks on behalf of my child(ren). In the event of emergency and neither I nor my emergency contact can be reached, I authorize the management at Starlite Family Fun Center to have my child transported to the nearest emergency facility. I also understand that all monies paid for camp are non-refundable.

(770) 252-9500

Sign up for Summer of 2023!

Additional Siblings Attending

Additional Information

Terms and Conditions

Sign up for Summer of 2023!

Additional Siblings Attending

Additional Information

Terms and Conditions

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