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 Name
Last Name
Age
Gender
*
Choose one
Male
Female
Please select one from the list
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardian Details
Primary Guardian Relationship
*
Choose one
Father
Mother
Step-father
Step-mother
Foster-father
Foster-Mother
Adopted Father
Adopted Mother
Aunt
Uncle
Other (Please specify)
Specify Other
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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 Name
Middle Name
Last Name
Relationship
*
Phone Number
*
Allergies or Intolerance to Food, Medication, etc., and Action to Take in an Emergency
*
Parent/Guardian Signature
*
Parent/Guardian's Typed Name
*
Please type your full name for acknowledgment
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Badr Summer Camp | BCCD
www.bccd.org
| (703) 221 BADR
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