Online Registration

2018 imagine That! Registration Form

Sorry- All the registrations for imagine That! 2018 are filled.

If you want to be put on a waiting list please contact imaginethat@pbseugene.com



New Location!
The Village School
3411 Willamette Street
Eugene, OR

Please be advised that July 4 will be a regular camp day.


 

Camp Information


Please select the camp you want to register for using the options below.
At checkout you will be provided the option to pay with a $40 deposit or the full amount.
  *Camp Date  
  *Camp Hours  


 

Student Information

  *Student's Name  
  *Address  
  *City       *Zip  
  *Grade  
  *Age  
  *School  


 

Parent/Guardian Information

 
Parent/Guardian
  *Name  
  *Email  
  *Home Phone  
  Work Phone  
  *Emergency Contact Name  
  *Emergency Contact Phone  
  Paypal Email   Only if different than parent email
 
Second Parent/Guardian (optional)
  Full Name  
  Phone  
  email  
 
Additional Contacts (optional)
Others who are authorized to pick up your child from camp.
  Name  
  Phone  
 
  Name  
  Phone  
 
  Any Other Parent Info We Should Know


 
 

Medical Information and Authorization

  Allergies/medical conditions important for us to be aware of:
 
*Is your child currently receiving medication? No Yes
 
I give permission to the summer camp staff to assist my child with prescribed medication? (if applicable)
 
Emergency Medical Treatment Authorization:
As a parent or legal guardian of the above-mentioned child, by submitting this camp registration form, I hereby authorize “Imagine That!” staff to call an ambulance or take my child to any available physician or hospital at my expense if a parent or legal guardian cannot be reasonably located when the child is brought for treatment. This authorization will expire on the completion of the assigned camp.

*Parent or legal guardian name:

Date: