Summer Camp Enrollment Form

Summer Day Camp Registration

A Summer Where Every Child Is Valued & Loved
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Age*
Behavioral Issues/Concerns*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Medical Concerns (ex. Allergies)
Should be Empty: