Summer Camp Pre - Registration Form

Youth Exposure, Inc Summer Camp Registration Form

Fill out the form carefully for registration. 30 Slots Available. Accepting Boys & Girls 10-19 years old.
Student Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*
Phone Number*
PARENTS / GURARDIAN CONTACT*
Please enter Parents telephone number to authorize students attendance. No student will be allowed to attend any 3-day camp without parents permission
Parent / Guardian First & Last Name*
Example: Jane Doe
Courses*
Summer Program Hours Mon, Tues, Thurs, Fri 12pm -5pm & Wed 10am - 3pm. After School Program Hours ( Mon, Tues, Thurs & Fri 2pm - 7pm )
Additional Comments
Parent / Guardian Signature*

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PARENT/GUARDIAN MUST SIGN THIS FORM FOR CHILD /PARTICIPANT TO REGISTER FOR SUMMER CAMP OR AFTERSCHOOL PROGRAM.
Please download and complete application.*
Please download and complete photo release form.*
Please download and complete activity waiver. *
Should be Empty:

Youth Exposure, Inc Summer Camp Registration Form