Summer Camp Enrollment Form

Breakthrough Inertia 2024

Summer camp location- Immanuel Church 2414 Pennsylvania Ave, Wilmington De 19806
CHILD INFORMATION:
Child Name

First NameLast Name
Student ID #
Gender
Race
Enrollment Date

MonthDayYear
Birth Date

MonthDayYear
Grade (fall of 2024)
Name of School
District
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number

Area CodePhone Number
Medical Concerns
Should be Empty:

Breakthrough Inertia 2024