2011 Chamberlain Golf Camp Registration

Complete this form and press the SUBMIT button.

Your registration is not considered complete until PAYMENT and the WAIVER FORM are received. The WAIVER FORM is available on-line and may be submitted together with payment. Payment may also be made separately via an on-line banking account. Sorry, we do not accept credit/debit cards.


Please submit a separate registration for sibling campers and/or multiple camp weeks.

Please note: After submitting this form, you may be directed to the www.quia.com website. You can simply CLOSE YOUR BROWSER WINDOW at that time.

Thank you!


A red asterisk (*) indicates required questions.

  1. Camper's Name (Last, First)*


  1. Birth Date (mm/dd/yyyy format)*


  1. School Grade Level in September 2011:*
    K-2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12


  1. Choice of camp week beginning:*
    Mon, June 27th
    NO CAMP week of July 4th
    Mon, July 11th
    Mon, July 18th
    Mon, July 25th
    Mon, August 1st
    Mon, August 8th
    Mon, August 15th WAITLIST ONLY; PLS CALL 973-634-8379


  1. Camp level (see the website for program descriptions):*
    PeeWee ($179/week Mon-Thurs 8am-10am)
    Level 1 ($299/week Mon-Thurs 8am - 12 noon)
    Level 2 ($369/week Mon-Fri 8am - 12 noon)
    Level 3 ($459/week Mon-Fri 8am - 1pm)


  1. Street Address*


  1. City, ST ZIP*


  1. Primary parent/guardian name (Last, First):*


  1. Parent/guardian e-mail id:*


  1. Home phone number:*


  1. Parent/guardian cell phone number:


  1. Secondary/emergency contact name (can be spouse, relative, friend):


  1. Secondary/emergency contact phone (preferably cell):


  1. Payment/registration options:

    (Note: When you are done with this form, click on the [submit answers] button below. You may be directed to the Quia.com website... you can simply close the browser window at that time.)

    You may select one of the following payment/registration options:


    *
    I will print, sign and mail the registration/waiver form and include a check payable to "Chamberlain Golf."
    I will print, sign and mail the registration/waiver form and make a separate payment from my on-line banking checkbook payable to "Chamberlain Golf."