CED 172- 90 Health Care Camp

July 8th, 9:00 am-3:00 pm
Parent's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Child's Name

First NameLast Name
Child's Birth Date

MonthDayYear
Grade that camper will be enrolled in 2019-2020
I have been a resident of Maine since: (Note: answer does not exclude you from participating)
Please let us know if there is anything specific we should know about working with your child
How did you hear about this camp?

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Should be Empty:

July 8th, 9:00 am-3:00 pm