Camper Name
*
Parent Name
*
Address
*
City
*
State
*
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
Zip
*
Parent Phone
*
Parent Cell Phone
*
Parent Email
*
Camper Gender
*
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Male
Female
Camper Date of Birth
*
-
Month
-
Day
Year
Date
Camper Shirt Size
*
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Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
How did you hear about Camp Courage?
*
How has your child's life been affected by cancer?
*
Will your child be riding the bus from our office location on Red Bank Expressway?
*
Yes
No
Does your child have any special needs? If yes, please explain:
Does your child have any allergies? If yes, please explain:
Does your child have any dietary restrictions? If yes, please explain:
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