Forms should be returned with
your payment (credit card or
check made payable to The
Prairie School)
Send to:
Director of Summer Programs
The Prairie School
4050 Lighthouse Dr.
Racine, WI 53402
Confirmation will be sent once
registration and payment are
received.
USE THIS FORM FOR ALL PROGRAMS EXCEPT HAWK'S HAVEN!
USE SEPARATE FORM PER CHILD. PHOTOCOPY IF NECESSARY.
STUDENT NAME____________________________________________________________________________
AGE_______ DATE OF BIRTH____/____/________ MALE FEMALE
ADDRESS____________________________________ CITY/STATE/ZIP_______________________________
CURRENT GRADE ___________ CURRENT SCHOOL______________________________________________
COURSE# TITLE DATE TIME FEE
Registration for any Sports Camp requires Concussion Acknowledgement
form for each participant!
PARENT INFORMATION - ALL INFORMATION MUST BE COMPLETED
Circle one: Mr. / Mrs. / Dr. / Ms. Circle one: Mr. / Mrs. / Dr. / Ms.
Parent/guardian 1____________________________ Parent/guardian 2_________________________________
Address___________________________________ Address________________________________________
City,State, Zip______________________________ City,State, Zip_____________________________________
Home phone_______________________________ Home phone______________________________________
Work phone_______________Cell______________ Work phone___________________Cell________________
E-mail_____________________________________ E-mail_________________________________________
Name of person(s) authorized to pick-up child______________________________________________________
Are there any health matters/conditions (e.g. allergies) that Prairie should be aware of? _____________________
___________________________________________________________________________________________
Primary Care Physician_______________________________________ Phone#__________________________
Enclosed is my payment of $_________(full payment is required with registration)
VISA Mastercard (credit card authorization is for initial balance AND any subsequent 2013 enrollment)
Name on card___________________________________ Card #_____________________________________
Exp. date_____________ Signature_____________________________________________________________
A full refund will be allowed if cancellation is requested by June 1, 2013. I authorize this student to
participate in Prairie's 2013 SUMMER PROGRAM. Prairie Summer Programs reserves the right to refuse
enrollment to students who demonstrate disruptive or unsafe behavior with no refund. Prairie Summer
Programs reserves the right to cancel any camp or program that does not meet minimum enrollment
requirements. I authorize Prairie's Director of Summer Programs or designee to arrange for emergency
treatment by qualified personnel for my child. I understand that photographs of my child may be used in
The Prairie School promotional materials.
_____________________________________________________________________________________________________________________
Parent/guardian signature Date
Registrations without Parent/guardian signature will be returned!
SUMMER PROGRAM REGISTRATION FORM
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