Camp Endeavor Online Application

Camper’s Name:

Birth Date:

Address:

City:

State:

Zip Code:

Phone:

Work or Cell Phone

Email Address:

Does your child receive reduced or free lunch at school?

Camper’s Height:

Camper’s Height: :: Campers height in feet and inches

Weight:

Weight: :: Weight in lbs.

Male/Female Select One:

Approximately how long has the camper been challenged by weight?

Referred to Camp Endeavor by:

Father’s Name:

Address (if different):

Mother’s Name:

Address (if different):

Payment Information * Two week tuition is $2,000.00 * Four week tuition is $3700.00 * Tuition may be income tax deductible. * To enroll, a deposit of $300.00 is required with this agreement. * Tuition balance is due before June 1, 2010. * A cancellation fee will be assessed according to the following schedule: * No refund will be given if cancellation occurs after June 13, 2010. * A check, money order, or PayPal (use any credit card) are the methods of payment we currently accept. * Financing is available, contact us for details. ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

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Session 1: June 20 - July 3
Session 2: July 4 - July 17
Session 3: June 20 - July 17

I have read the terms of enrollment above and am familiar with the same and agree that this enrollment is acceptable to me and is subject to everything contained therein. In the event that this agreement is executed by one parent, I acknowledge that I am also acting as the agent of the other parent with the authority to so enroll my child at Camp Endeavor and to execute this agreement on his or her behalf. I recognize that Camp Endeavor relies upon the representations herein made in accepting my child. Camp Endeavor reserves the right to refuse admission based on medical/psychological history or care.

I Agree: