Summer camp registration

Camper Registration/Medical Form 

 Camp Address: 9-10 Saddle River Rd, Fair Lawn, NJ 07410 


Camp Dates ____________        Student Name: _______________           Nickname: ______________

Date of Birth: _____________      Age (at the time of the Camp): ______                   Grade: ___________

Name of School/ Address: ____________________________________ __________________ __    

Parent #1  Full Name: _______________________________Cell Phone______________________

Facebook Contact__________________________Email Address ___________________________

Parent #2 (2nd Contact) __________________________   Cell Phone________________________

Facebook Contact__________________________Email Address ___________________________

Home address: _________________________________      State: _____    Zip Code:____________  

Best Way to contact you  _______________________________Work Phone___________________

EMERGENCY CONTACTS (please provide two additional people, different from the parent/guardian listed above, who would automatically be the first person we contact)

First Contact’s Name: ________________________________Relationship:__________________

Cell Phone: ____________________ Email: _______________________________ 

Second Contact’s Name: ______________________________Relationship:__________________

Cell Phone: ____________________ Email: _______________________________ 

Medical information:

Insurance # and provider name/phone number:_________________________________________

Medical Doctor name and Phone number:______________________________________________

Medication in use:______________________________________________________________

Vaccination list/ dates – Please add a copy of current immunization record!

SAFETY INFORMATION (please list all known conditions so we can accommodate your camper’s needs)

Does your camper have any medical conditions, allergies, or special needs the staff should know about?

YES/ NO, specify if yes

Does your camper have any behavioral or emotional issues the staff should know about?

YES/ NO, specify if yes

Is your camper taking any medications to treat these conditions?

YES/ NO, specify if yes

Other information you think we should know (please add a page if needed)

Do you need Afterhours! YES/ NO,   specify if yes:  Am/ Pm/ Both

If you are need afterhours (7-9am or 3-6pm) please submit the list of dates/hours to [email protected]  You will need to fill an extra form.

Refund and Cancellation: For cancellations made prior to May 15, a refund minus $250 non-refundable deposit will be issued. For cancellation after May 15, the total fee is forfeited. In the event that your child enrolls in camp and withdraws because of homesickness there will be no refund, but we may offer a different session in case we have space free of charge.

Camper Dismissal: A camper whose behavior is disruptive to the camp program or harmful to himself/herself, others, or the property of camp will be dismissed at the discretion of Camp Owners, with no refund of fee.

Testimonials. We, the undersigned parents (or guardians) of the camper named on this application, acknowledge that we are fully aware that certain elements of danger are inherent in the activities sponsored by Camp Providers (Upper West Art LLC), which are beyond the control of the agents, the land owners and employees of Camp, and that participation in any program activities may entail unavoidable risk of personal injury, death, and loss of or damage to property. We are aware of the types of activities in which the child will be participating during his/her stay and have been given ample opportunity to ask any questions which we may have about the environment the child will live and the activities that he or she will participate in. We are aware of the dangers that are inherent in the operation of any child’s camp and in the child’s participation in all camp activities on or off premises of said camp including, but not limited to, running, athletics, including bodily contact, use of tools and equipment, outdoor-living skills, and vehicular travel. We grant permission to use any photograph or video for promotional use.

We have read and understand the terms and conditions of this Agreement/Waiver and we agree to subscribe to them.

Parent/Guardian Name___________________________________ Date: ___________

(if only one signature, consent is implied from other parent)

I verify that all the information I have provided in this document is true to the best of my knowledge.

Your signature/ print name:




Camp is Monday-Friday, 9:00-3:00, with a possible after-hours at All Bright Summer camp for an additional fee. Email us if you need aftercare, before the camp starts! Camp provides all the necessary instruments, equipment, and teachers , as well as a snack and a hot lunch. Campers may bring lunch box just in case, or if special dietary restrictions apply. Please make sure to bring a water bottle for our outdoor activities.  You should also have a change of comfortable summer wear, extra shorts, tees, clothing suitable for art and messy paints (an old T-shirt is perfect!), sandals, swimwear and towel (we use sprinklers when weather permits), sun block, hats as we will be outdoors every day. Please do not bring any electronic devices including cell phones. If you need a child to have a cell phone- please hand it over to a teacher upon arrival! See you in our Camp!

Lena, Dasha, Borya

914-772-6919 / 845-323-1960          [email protected]