Empower Youth Application

Part I - Personal Information
Cultivate Fertile Minds Application

YOUTH SUMMER CAMP
Applicant Name*

First NameLast Name
Child Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shirt Size (check box)

XSSMLXL
Allergies:
How did you hear about us?*
Part II - Parent/Guardian
Parent Name*

First NameLast Name
Phone Number*
Email Address*
Part III - Education
School Name*
Location*
Current Grade*
Part IV - Additional Children (To enroll in program)
Child Name

First NameLast Name
Child Age*
Shirt Size (check box)

XSSMLXL
Allergies:
Emergency Contact:
Will you be willing to recommend us?

YesNo
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Youth Summer Camp - Week 4Register youth 5-13 for our summer camp today!! $125 a week
$125.00 Quantity
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Youth Summer Camp - Week 5Register youth 5-13 for our summer camp today!! $125 a week
$125.00 Quantity
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Youth Summer Camp - Week 6Register youth 5-13 for our summer camp today!! $125 a week
$125.00 Quantity
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Youth Summer Camp - Week 7Register youth 5-13 for our summer camp today!! $125 a week
$125.00 Quantity
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Youth Summer Camp - Week 8Register youth 5-13 for our summer camp today!! $125 a week
$125.00 Quantity
Item subtotal:$0.00



Total

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Cultivate Fertile Minds Application