Please enable JavaScript in your browser to complete this form.Student Name *FirstLastDate Of Birth *Incoming Grade Level *PreschoolPK3PK4Kindergarden1st Grade2nd Grade3rd Grade4th Grade5th GradeAre you a Galloway Student? If not, what school do you attend? *Mother's Name *FirstLastMother's Cell Phone *Mother's Email *Father's Name *FirstLastFather's Cell Phone *Father's Email *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact #1 *FirstLastEmergency Contact #1 Relationship *Emergency Contact #1 Phone *Emergency Contact #2FirstLastEmergency Contact #2 RelationshipEmergency Contact #2 PhonePhysician's Name *FirstLastPhysician's Phone *Preferred HospitalMedicationsAllergiesSummer Camp (No Aftercare)Summer 8 Week Contract - $2,000Summer Session 1 - June - $1,100Summer Session 2 - July - $1,100Summer Week 1 Drop In: June 5-9 - $300Summer Week 2 Drop In: June 12-16 - $300Summer Week 3 Drop In: June 19-23 - $300Summer Week 4 Drop In: June 26-30 - $300Summer Week 5 Drop In: July 5-7 - $300Summer Week 6 Drop In: July 10-14 - $300Summer Week 7 Drop In: July 17-21 - $300Summer Week 8 Drop In: July 24-28 - $300Summer Camp (With Aftercare)Summer 8 Week Contract - $2,160Summer Session 1 - June - $1,180Summer Session 2 - July - $1,180Summer Week 1 Drop In: June 5-9 - $320Summer Week 2 Drop In: June 12-16 - $320Summer Week 3 Drop In: June 19-23 - $320Summer Week 4 Drop In: June 26-30 - $320Summer Week 5 Drop In: July 5-7 - $320Summer Week 6 Drop In: July 10-14 - $320Summer Week 7 Drop In: July 17-21 - $320Summer Week 8 Drop In: July 24-28 - $320Is this your 2nd or 3rd student enrolled? *YesNoThere is a 15% sibling rebate which will be returned via PayPal within 10 business days.Total$ 0.00Comment or MessageEmailSubmit Please note: Camp Hours: 8:00AM – 3:15PM Aftercare Hours: 3:30PM – 6:00PM *DAILY RATES: $73 Camp Only or $83 Camp with After-Care **At least 24-hours’ notice REQUIRED