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

*Address
  *City/State   *Zip
*Cell
  Work
*Emergency contact name
    *Phone

* Select one of the following:
Wk 1 July 11-14

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

Wk 2 July 25-28 FULL
Wk 3 August 1-4 FULL

 

Chelsea's Tea Room & Boutique Release

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

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

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

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

 
No Yes
  Anything else we should know about your daughter?
 
 

ACKNOWLEDGEMENT
*
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