Registration Form

Summer Camp Application

BADR COMMUNITY CENTER OF DUMFRIES, VA
CHILD REGISTRATION FORM
Desired Session (Select all that apply)*

One (Jul 15 - Jul 18)Two (Jul 22 - Jul 25)Three (Jul 29 - Aug 1)Four (Aug 5 - Aug 8)
Child's Details
Name*

First NameLast Name
Age
Gender*
Please select one from the list
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Details
Primary Guardian Relationship*
Specify Other
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Email*
example@example.com
Authorization

I agree to be added to the WhatsApp Group for updates.
Emergency Contact Information
Primary Emergency Contact Name*

First NameMiddle NameLast Name
Relationship*
Phone Number*
Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency*
Parent/Guardian Signature*

Clear
Parent/Guardian's Typed Name*
Please type your full name for acknowledgment
Date Signed*

MonthDayYear
Date
Badr Summer Camp | BCCD
www.bccd.org | (703) 221 BADR
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Summer Camp Application