The Art of Summer Camp Enrollment Form

Summer Camp Registration
CHILD INFORMATION:
Child Name *

First Name Last Name
Child Likes To Be Called
Birth Date *

Month Day Year
Grade *
Name of School *
Summer Program Option *
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number *

Area Code Phone Number
Mobile Phone Number *

Area Code Phone Number
E-mail *
Emergency Contact Information
Emergency Contact Name *

First Name Last Name
Home Phone Number

Area Code Phone Number
Mobile Phone Number *

Area Code Phone Number
MEDICAL INFORMATION
Physician Name *

First Name Last Name
Phone Number

Area Code Phone Number
Medical Record Number *
Medical Concerns
Please include any allergies, dietary restrictions, etc
Signature *

Clear
Should be Empty:

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