Wytha Balance Yoga Intersession Camp Application

Wytha Balance Yoga Intersession Camp Application
Child's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Where does your child currently attend school? What is the current grade?
What is your childs birthdate? Month, Date and Year
FemaleMale

September 23 - 26, 2025October 6 - October 10, 2025December 15 - December 19, 2025March 16 - March 20, 2025

AllergiesMedicationEmotional BehaviorSpecial CircumstancesNone

Mother/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Father/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name of person to pickup child(ren) in case of an emergency if parents can not be reached.

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In case of an emergency - Childs Doctor

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child Dentist

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Preference
Insurance Company & Policy #
Policies, Procedures and Payment

https://docs.google.com/document/d/1oFe3nXMWgsxdXeDjGJC5nZq4oMOV32vf/edit?usp=sharing&ouid=108679619063062776718&rtpof=true&sd=true

payment link: www.paypal.com/paypalme/bullcityyogafestival

Applications due: when payment is sent.

Cashier Checks or Money orders can be mailed to:

Ingrid Saddler-Walker - Wytha Balance Yoga Creative Summer Camp

1301 Clermont Road

Durham, NC 27713
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