Camp Dominion | Zion Dominion (ZDGM)

CAMP DOMINION

Enjoy 6-weeks of summer camp with a wide range of outdoor adventures, learning activities, arts & crafts, and more for children who are potty trained, ages 3-12. Our experienced counselors are dedicated to helping your child grow, make new friends, and build self-confidence. With breakfast and lunch included, tuition is affordable and family-friendly.

Director

Sis. Lanita Blackmon

(716) 250-7040 ext. 113

lblackmon@ziondominion.org

Co-Director

Sis. Candace Dowdell

cdowdell@ziondominion.org

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Online Registration Form
CAMP DOMINION 2024
*accepting CASH, CHECK and/or MONEY ORDER payments only!

Child's Information

Child's First Name

Middle Name (if any)

Child's Last Name

Birthday

Child's current school & school district

What kinds of special services, if any, does your child receive both at school and outside of school? (ex. OT, speech and language therapy, classroom aid, IEP, etc.)

Child's Street Address

Suite/Apt #

City

State

ZIP Code

Child's Guardian Information

First Name (Parent/Guardian 1)

Last Name (Parent/Guardian 1)

Confirm Email

Cell Phone

Home Phone

Work Phone

Address if different from child (Parent/Guardian 1)

First Name (Parent/Guardian 2)

Last Name (Parent/Guardian 2)

Address if different from child: (Parent/Guardian 2)

Emergency Contact

First Name (Emergency Contact)

Last Name (Emergency Contact)

Phone

Relationship to child

Child's Medical Information

Child's Pediatrician Name

Pediatrician's Address:

Pediatrician's Number

Insurance

Policy #

Is your child currently taking any medications? If so please list, including dose & time taken.

What is your child's current/most recent diagnosis? who made the diagnosis?

Does child have any allergies, significant health conditions, limitations, and/or food restrictions? If yes, explain.

Is the child prescribed an inhaler? If yes, please explain any instructions.

Certification

How many children will you be registering?

1 Child

2 - 3 Children

4+ Children

I certify that the information is complete and accurate to the best of my knowledge.

I also understand that my child IS NOT registered until the registration fee is PAID IN FULL.

I agree to the terms & conditionsView terms of use

Your Signature