Summer Program Registration

2023 Summer Program Registration Form
(9 - 12, 12:30 - 3:30 or 9 - 3:30pm)

Student's Name*

First Last

Age*

Please enter a number from 5 to 13.

Players age 5 - 7 may only register for Morning Programs

Parent Information

Parent's Name*

First Last

Address*

Street Address City State ZIP Code

Parent's Email Address*

Enter Email Confirm Email

Home Phone*

Parents's Mobile Phone

Parent's Office Phone

I am a Potomac Swim & Tennis Club Member

Yes
No

Packages (Multiple Weeks)

Package Options [NMbr]

4 Weeks of Morning (9-12) $1200 [NON-MEMBER]
4 Weeks of Afternoon (12:30-3:30) $1200 [NON-MEMBER]
4 Weeks of Full Day (9-3:30) $2120 [NON-MEMBER]
8 Weeks of Morning (9-12) $2240 [NON-MEMBER]
8 Weeks of Afternoon (12:30-3:30) $2240 [NON-MEMBER]
8 Weeks of Full Day (9-3:30) $4000 [NON-MEMBER]
Nothing/Clear

Package Options [Mbr]

4 Weeks of Morning (9-12) $1020 [MEMBER]
4 Weeks of Afternoon (12:30-3:30) $1020 [MEMBER]
4 Weeks of Full Day (9-3:30) $1810 [MEMBER]
8 Weeks of Morning (9-12) $1910 [MEMBER]
8 Weeks of Afternoon (12:30-3:30) $1910 [MEMBER]
8 Weeks of Full Day (9-3:30) $3400 [MEMBER]
Nothing/Clear

Select Desired Package Weeks (4 or 8)

Additional weeks can be purchased at the discounted rate via emailing admin@passacademypstc.com

Individual Weeks

Week 0n: June 12 - 16 [NMbr]

Morning Camp (Wk0) $330 [NON-MEMBER]
Afternoon Camp (Wk0) $330 [NON-MEMBER]
Full Day Camp (Wk0) $590 [NON-MEMBER]
Nothing/Clear

Week 0n: June 12 - 16 [Mbr]

Morning Camp (Wk0) $290 [MEMBER]
Afternoon Camp (Wk0) $290 [MEMBER]
Full Day Camp (Wk0) $510 [MEMBER]
Nothing/Clear

Week 1n: June 20 - 23 (4 days) [NMbr]

Morning Camp (Wk1) $270 [NON-MEMBER]
Afternoon Camp (Wk1) $270 [NON-MEMBER]
Full Day Camp (Wk1) $440 [NON-MEMBER]
Nothing/Clear

Week 1n: June 20 - 23 (4 days) [Mbr]

Morning Camp (Wk1) $240 [MEMBER]
Afternoon Camp (Wk1) $240 [MEMBER]
Full Day Camp (Wk1) $410 [MEMBER]
Nothing/Clear

Week 2n: June 26 - 30 [NMbr]

Morning Camp (Wk2) $330 [NON-MEMBER]
Afternoon Camp (Wk2) $330 [NON-MEMBER]
Full Day Camp (Wk2) $590 [NON-MEMBER]
Nothing/Clear

Week 2n: June 26 - 30 [Mbr]

Morning Camp (Wk2) $290 [MEMBER]
Afternoon Camp (Wk2) $290 [MEMBER]
Full Day Camp (Wk2) $510 [MEMBER]
Nothing/Clear

Week 3n: July 5 - 7 (3 days) [NMbr]

Morning Camp (Wk3) $200 [NON-MEMBER]
Afternoon Camp (Wk3) $200 [NON-MEMBER]
Full Day Camp (Wk3) $360 [NON-MEMBER]
Nothing/Clear

Week 3n: July 5 - 7 (3 days) [Mbr]

Morning Camp (Wk3) $170 [MEMBER]
Afternoon Camp (Wk3) $170 [MEMBER]
Full Day Camp (Wk3) $310 [MEMBER]
Nothing/Clear

Week 4n: July 10 - 14 [NMbr]

Morning Camp (Wk4) $330 [NON-MEMBER]
Afternoon Camp (Wk4) $330 [NON-MEMBER]
Full Day Camp (Wk4) $590 [NON-MEMBER]
Nothing/Clear

Week 4n: July 10 - 14 [Mbr]

Morning Camp (Wk4) $290 [MEMBER]
Afternoon Camp (Wk4) $290 [MEMBER]
Full Day Camp (Wk4) $510 [MEMBER]
Nothing/Clear

Week 5n: July 17 - 21 [NMbr]

Morning Camp (Wk5) $330 [NON-MEMBER]
Afternoon Camp (Wk5) $330 [NON-MEMBER]
Full Day Camp (Wk5) $590 [NON-MEMBER]
Nothing/Clear

Week 5n: July 17 - 21 [Mbr]

Morning Camp (Wk5) $290 [MEMBER]
Afternoon Camp (Wk5) $290 [MEMBER]
Full Day Camp (Wk5) $510 [MEMBER]
Nothing/Clear

Week 6n: July 24 - 28 [NMbr]

Morning Camp (Wk6) $330 [NON-MEMBER]
Afternoon Camp (Wk6) $330 [NON-MEMBER]
Full Day Camp (Wk6) $590 [NON-MEMBER]
Nothing/Clear

Week 6n: July 24 - 28 [Mbr]

Morning Camp (Wk6) $290 [MEMBER]
Afternoon Camp (Wk6) $290 [MEMBER]
Full Day Camp (Wk6) $510 [MEMBER]
Nothing/Clear

Week 7n: July 31 - Aug 4 [NMbr]

Morning Camp (Wk7) $330 [NON-MEMBER]
Afternoon Camp (Wk7) $330 [NON-MEMBER]
Full Day Camp (Wk7) $590 [NON-MEMBER]
Nothing/Clear

Week 7n: July 31 - Aug 4 [Mbr]

Morning Camp (Wk7) $290 [MEMBER]
Afternoon Camp (Wk7) $290 [MEMBER]
Full Day Camp (Wk7) $510 [MEMBER]
Nothing/Clear

Week 8n: Aug 7 - 11 [NMbr]

Morning Camp (Wk8) $330 [NON-MEMBER]
Afternoon Camp (Wk8) $330 [NON-MEMBER]
Full Day Camp (Wk8) $590 [NON-MEMBER]
Nothing/Clear

Week 8n: Aug 7 - 11 [Mbr]

Morning Camp (Wk8) $290 [MEMBER]
Afternoon Camp (Wk8) $290 [MEMBER]
Full Day Camp (Wk8) $510 [MEMBER]
Nothing/Clear

Week 9n: Aug 14 - 18 [NMbr]

Morning Camp (Wk9) $330 [NON-MEMBER]
Afternoon Camp (Wk9) $330 [NON-MEMBER]
Full Day Camp (Wk9) $590 [NON-MEMBER]
Nothing/Clear

Week 9n: Aug 14 - 18 [Mbr]

Morning Camp (Wk9) $290 [MEMBER]
Afternoon Camp (Wk9) $290 [MEMBER]
Full Day Camp (Wk9) $510 [MEMBER]
Nothing/Clear

Total Fees

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Session

Summer: June 12th - August 18th 2023

Medical Authorization & Release

Camper Name*

First Last

Camper Condition*

By checking this box it is understood that the student is in overall good physical health. If your child has a physical condition that may limit or restrict participation in certain activities, a physician’s note granting permission to participate in such activities must be presented prior to the first camp session.

Date of Medical Authorization*

By dating above, in an emergency, when I/we cannot be contacted, I/we hereby authorize the staff of the Pass Academy to take my/our child to the emergency room of the nearest hospital. I/we authorize that hospital and its medical staff to provide treatment deemed necessary for the well-being of my/our child.

Date of Parent Release*

By dating above, I agree to hold the Pass Academy and Potomac Swim & Tennis Club harmless for injury or loss that may occur as a result of my participation in Pass Academy activities.

Cancellation Policy*

By checking this box I accept the following policy. All refunds prior to the start of the program are subject to fee charges of 6%. No refunds after the start of the program.

Permission for Photo Use*

Yes
No

I give permission for photos of my child participating in Pass Academy at Potomac Swim & Tennis Club programs to be taken and used for the Pass Academy Website and/or Facebook page. We understand that if students are identified, only their first names will be used.

Additional Information (optional)