Reaching for the Stars Summer Camp Application

Stop the Violence Coalition, INC.
ACADEMY FOR PEACE

203 North Market Street, Wilmington, DE 19801
Camper ID
Registration Date

MonthDayYear
Date
Office Program Notes Only
APPLICATION FORM FOR
Reaching for the Stars

Summer Camp
PARENT/GUARDIAN INFORMATION
Name
E Mail
example@example.com
Date Of Birth

MonthDayYear
Date
Full Address
City
Zip Code
Phone Number

Area CodePhone Number
Emergency Contact
Name and Phone Number
Drivers License

YesNo
Driver License Number
CHILD/ CHILDREN NAMES AND AGES
Child 1:
Child 2:
Child 3:
IF ANY CHILD HAS MEDICAL/SPECIAL NEEDS PLEASE LIST HERE
I hearby release, hold harmless defend and idemnify the Academy for Peace, from any and all damages, injuries and causes of action which may accrue to or be asserted by me or any minor child of mine arising directely or indirectly from my minor child's participation in The Academy for Peace Reaching for the Stars Summer Camp.

ACADEMY FOR PEACE