CAMP SCATICO

2020 Camper Enrollment Form FOR the 1-wEEK PROGRAM

Camper's Name

First Name

Last Name

Gender

Grade in September 2019

Date of Birth

YYYY

Parent(s)/Guardian(s)

Street, City, State, Zip

Phone Numbers

Email Addresses

Another Home Address

Second Parents/Guardians At Another Home Address

Street, City, State, Zip

Phone Numbers

Email Addresses

Emergency Contact Information in Addition to Parent(s)/Guardian(s)

Emergency Contact Name

Relationship

Emergency Telephone, Cell Phone, Other

Payment Options (Please select ONLY one)

1) Pay By Mail

I will send a $500 deposit check to: Camp Scatico, PO Box 6, Elizaville, NY 12523

2) Pay By Electronic Check.

$500 deposit.

Bank Account Number

Routing Number

Name on Account

Name of Camper(s)

3) Pay By Credit Card.

$500 deposit. See payment link below.

Signature

Payment Method Confirmation

Yes, I selected one payment method from the Payment Method section.

Provided Information

All information on this form is accurate to the best of my knowledge. By electronically signing below you agree to the Terms and Conditions (see below)

Full Name

Terms and Conditions

Please note: If you selected Payment Option 3 (Pay by Credit Card) after submitting the Registration Form continue to "Pay By Credit Card Now" button below.