CentriKid Camp Registration 2017
CentriKid Camp Registration 2017
Where: Gardner-Webb University in Boiling Springs, North Carolina
Who: Children who have completed Grades 3-5 during the 16-17 school year
When: We will leave PCBC at 11:00 am on Monday, July 10th and return on Friday, July 14th at approximately 2:00 pm.
Cost: $300 per child. A deposit of $100 is required with this form and will reserve your child’s space.
You may also choose to pay the entire amount of $300 at the time of registration. You will receive an informational packet upon registering your child.
Register today as only a few slots remain.

JUNE 25th @ 5:00 PM in Room D-103

1st Child’s Name  * 
1st Child Boy/Girl:  * 
1st Child’s Birth Date: Month/Day/Year  * 
1st Child’s Grade completed in 2017:  * 
1st Child’s Allergies:
1st Child’s Current Medication:
1'st Child's Payment Options  * 
1st Child’s Special Needs:

2nd Child’s Name
2nd Child Boy/Girl
2nd Child’s Birth Date: Month/Day/Year
2nd Child’s Grade completed in 2017
2nd Child’s Allergies:
2nd Child’s Current Medication:
2nd Child’s Special Needs:
2nd Child's Payment Options  * 

3rd Child’s Name:
3rd Child Boy/Girl
3rd Child’s Birth Date: Month/Day/Year
3rd Child’s Grade completed in 2017:
3rd Child’s Allergies
3rd Child’s Current Medication
3rd Child’s Special needs
3rd Child's Payment Options  * 
Parent’s Information
Street Address:  * 
City/State/Zip:  * 
Home Phone:
Your Email Address  * 
Cell Phone: Mom:  * 
Cell Phone: Dad:  * 
Emergency Name 1:  * 
Emergency Phone 1:  * 
Emergency Name 2:  * 
Emergency Phone 2:  * 
Initial to agree with the above Medical Authorization, Release and Agreement.  * 
Total $
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