* required
*Child's first name 
   *Last name
*Birth date
Parents' names

  *City/State   *Zip
*Emergency contact name

* Select one of the following:
1 week only July 10-13

Four-day camp, Tuesday to Friday
11:00 am - 2:00 pm

Camp Cost:  $180    Ages 5 - 10

Includes: Manners/Etiquette Class
Cooking, Crafts,
Limousine Ride, Lunches,
Dress-up Tea Party and more

$50.00 cancelation fee    $10.00 late pick-up fee



Chelsea's Tea Room & Boutique Release

*Is your child allergic to anything which might be encountered this week?
  Food, paints, glues...

No Yes
*Is your child on any special medication or diet?

No Yes
*Are there any special medical problems which would affect her activities this week?

No Yes
*Are there any restrictions on your child's activities?

No Yes
  Anything else we should know about your daughter?

By checking this box, I, as the parent or guardian of the child described above, acknowledge and agree to the following:  In case of medical emergency, after every reasonable effort has been made to contact parent or guardian, I hereby give permission to Chelsea's Tea Room & Boutique to secure necessary treatment for the child. I have not been given a guarantee of the results of examination or treatment. I approve all camp activities, including travel to lunch via limousine.

I also give my permission for pictures to be taken and used online.

*Name of parent or legal guardian completing this form
*Email address for confirmation of registration