Summer Day Camp Registration

"*" indicates required fields

Step 1 of 2

Child Information

Child's First Name*

Child's Last Name*

Child's Date of Birth*

Child's 2023-24 Grade*

Years Playing Organized Hockey*

Will your child attend camp in Chaska or Eden Prairie?*

Chaska (Full)

Eden Prairie

Will your child attend camp four or five days a week?*

Please note any medical conditions or allergies.

If any, please explain typical accommodation.

Please note any academic, social, or emotional needs.

If any, please explain typical accommodation.

Please note any scheduled absences.

Due to staffing and facility costs, we are not able to pro-rate cost.

Please note placement requests.

Requests are not guaranteed.

Child's Primary Address*

Street Address Address Line 2 City State ZIP Code

Child's Secondary Address (If Applicable)

Street Address Address Line 2 City State ZIP Code

Parent Information

Primary Parent First Name*

(First contact in case of an emergency)

Primary Parent Last Name*

Primary Parent Mobile Phone Number*

Primary Parent Email*

Enter Email Confirm Email

Secondary Parent / Contact First Name*

Secondary Parent / Contact Last Name*

Secondary Parent / Contact Mobile Phone Number*

Secondary Parent / Contact Email*

Enter Email Confirm Email

Waiver

Click here to read the waiver.

Consent*

I acknowledge that I have read and understand the waiver.

Full Name*

This serves as an electronic signature.

Summer Day Camp Registration

Child Information

Parent Information

Waiver

Breakaway Academy
Chaska Campus

Breakaway Academy
Eden Prairie Campus

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