Summer Camp Detailed Registration Form

Horicon Library Summer Reading Registration 2023
Child's Information
Name

First NameLast Name
Birth Date

MonthDayYear
Grade in Fall
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Date

MonthDayYear
Date
Should be Empty:

Horicon Library Summer Reading Registration 2023