International Creative Arts Network
CHILD OF DESTINY SUMMER CAMP PROGRAM JULY 1 - AUGUST 9TH 2024
CAMP COST IS A NON- REFUNDABLE FEE OF 25.00 PER WEEK
PLEASE SUBMIT THE FULL PAY PAYMENT FOR THE FULL AMOUNT WEEKS YOUR CHILD WILL BE IN ATTENDANCE.
PAYMENT : RBC 05285-7264161 KEVIN G. TOMLINSON ACADEMY
Name
First Name
Last Name
name of school student attends
Birth Date
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Ethnicity
Please Select
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Grade
HOW MANY WEEKS DO YOU PLAN SPENDING WITH US!
HAVE YOUR CHILD ATTENDED OUR SUMMER CAMP BEFORE,
Yes
No
If yes, what year?
Current Residence Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Primary Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Emergency Contact 1
Name
First Name
Last Name
Phone Number
Email
example@example.com
Emergency Contact 2
Name
First Name
Last Name
Phone Number
Email
example@example.com
Physician and Medical Information
Name
First Name
Last Name
Phone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Back
Next
Previous School
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date Started
-
Month
-
Day
Year
Date
Date Ended
-
Month
-
Day
Year
Date
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Submit
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