Break Camp Online Registration

We Are Coaches, Inc.

On-line

Registration Form

(Download printable version - pdf)
(Download printable version - word)

Submit this form or mail a printable version and make checks payable to:
We Are Coaches, Inc. 2945 Cape Sebastian Place, Cardiff, CA 92007
Or phone in Visa/MC payment information
Call Peg Windisch (760) 436-1514
We will call or e-mail to confirm enrollment.

Name of program:
How did you find us?
1st Child's name:
Age: School:
Food Alergies/Restrictions:
2nd Child's name:
Age: School:
Food Alergies/Restrictions:
Parents Names:
Address:
City:   St:  Zip:
Home Phone: Cell Phone: Emergency Phone:
Your Email:
Check Days that child(ren) will be attending and fill in times.
Monday Tuesday Wednesday Thursday Friday Saturday
Attending:
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
Start Time:
Pickup Time:
My child(ren) will be picked up by:
1) Name: Phone:
2) Name: Phone:

Are there any specific academic or social values that you hope we focus on for your child in this program? Or other comments?

Please read and acknowledge the following by checking the checkbox. The form will not submit without this acknowledgement.
I hereby give permission to my son/daughter to participate in the We Are Coaches Program. I release and hold harmless We Are Coaches, Inc., its officers, director, agents, and sponsors (hereafter referred to as “Released Parties”) from any and all liability for injury to my person or property caused in any manner, including the negligence of the Released Parties, by my and my child’s participation in the Art & Fun hereby give permission for emergency first aid by enrichment personnel or a licensed medical doctor if necessary.
I understand that for a payment refund, I must cancel within 24 hours.
IMPORTANT NOTE:
Parents are responsible for prompt pick-up of your child. A $10 fee will be applied for late pick-up.