2023 Summer Camp Enrollment

2023 Summer Camp Registration
Child Name*

First Name Last Name
Birth Date*

Month Day Year
Age*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First Name Last Name
Parent/Guardian Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mother's Phone #*

Area Code Phone Number
Father's Phone #*

Area Code Phone Number
Mother's E-mail*
Father's E-mail*
example@example.com
MEDICAL INFORMATION
Physician Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Medical Concerns*
Date

MonthDay Year
Date
Signature*

Clear
Emergency Contact Name*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
Emergency Contact Name*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
Date

MonthDay Year
Date
Should be Empty: