Summer Camp Enrollment Form

P & J MINISTRY

Breakfast Program Registration
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Name of School*
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*
EMERGENCY CONTACT

In case a parent or guardian cannot be reached
Name

First NameLast Name
Phone Number

Area CodePhone Number
Please list any medical concerns including food Allergies
Should be Empty: