Parent(s) Name:
Address:
City:          Zip Code:   
Home Phone:    Work Phone:
Cell Phone:    Email:



Child's Name: DOB: Grade in Fall:1st2nd3rd4th5th6th7th8th Shirt Size: Youth 6/8Youth 10/12Youth 12/14Youth 18/20Adult SmallAdult MediumAdult LargeAdult X-Large

Camp Sessions: Basketball (6/23) Technology (6/30) Soccer (7/7)   Volleyball/Golf (7/14)
                        Football/Cheerleading (7/21)  Visual Arts (7/28)   Creative Arts (8/4)  Baseball (8/11)
                        Martial Arts / Tennis / Bowling (8/18)

Before Camp Care (7:30 - 8:30)    After Camp Care (5:00 - 5:45)    $15/week for one or $25/week for both


Medications:  Allergies:Bee StingsMedicationFoodDairyOtherNone 
Medical or Physical Restrictions Medical Issues :
Date of last tetanus:  Are immunizations up to date?  yes  no

Physician Name/Address/Phone Number:  Preferred hospital Bronson
                                                                                                                                     Borgess 
Health Insurance Policy #:   Group Number:
Dentist Name/Address/Phone Number: Emergency Contact:

By signing my initials, I, the legal guardian of the above named child authorize New Genesis Inc. to seek medical treatment for my child as they deem necessary.  I consent to any medical or surgical treatment deemed necessary by a licensed health care provider.  I understand that whenever possible, New Genesis Inc. staff will make a good faith effort to contact me or the alternative emergency contact before seeking treatment.  Initials:

Name and phone number of those authorized to pick your child up:

I have read the camp rules and explained them to my child.          I acknowledge that I have thoroughly read and understand the
By checking this box my child and I agree to abide by them.    field trip and transportation release.  By checking this box, I
                                                                                       grant permission to New Genesis MerryMaker's Summer  
I give my consent and permission for the taking of                     Camp & it's staff to transport my for camp events.
photographs and/or video of my child for projects and 
future promotions. 


TUITION & PAYMENT OPTIONS


Your tuition cost is per session.  We do not have a sliding scale or offer scholarships, however we've tried to make the cost of the camp very affordable for families.  We do offer a sibling discount and if you are employed and FIA eligible, FIA will cover your cost of the camp.  Many of the foster care agencies also have funding available to pay for foster children to attend the camp.
               (Please note - FIA / DHS will not cover your $25 registration fee.  You will be responsible for this cost.)

You may pay on a weekly basis or pay all of your camp upfront.  If you pay your entire tuition prior to the start of camp, you will receive the 9th week of camp free.  If you choose to pay weekly, your tuition is due the Friday PRIOR to the session you are attending.  There is a $25/family registration fee. 

This year we are offering before and after hours camp care.  Before care is from 7:30 am to 8:30 am and after care is from 5:00 pm to 5:45 pm.  The cost for before / after care is $15/week for one and $25/week for both. 

Payment may take or mail your payment directly to New Genesis at 1340 Cobb Ave in Kalamazoo or you may pay here online through PayPal.

Payment methods accepted are cash, money order, check, credit card, and FIA.

Please select the method of payment you wish to use.   Weekly    All upfront 

                  Cash      Check      Credit Card      Invoice Me      FIA