Summer Camp Registration Child Information Name of Child (Last, First, M.I.) * Nickname Sex * MaleFemale Date of Birth * Address * Does your child or either parent speak another language? Yes No If Yes, please specify the language. Child Background List any special needs that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of. Additional Comments or Instructions If you have more than one child to register (up to 2 more children), please check the boxes below and fill in the required information. Child #2 Child #2 Name of Child #2 (Last, First, M.I.) * Nickname Sex * MaleFemale Date of Birth * T-Shirt Size * XS (2-4)S (6-8)M (10-12) Child Background List any special needs that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of. Child #3 Child #3 Name of Child #3 (Last, First, M.I.) * Nickname Sex * MaleFemale Date of Birth * T-Shirt Size * XS (2-4)S (6-8)M (10-12) Child Background List any special needs that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of. Sessions Attending (Click all that apply) * Session 1: June 20, 22, 27 and 29 Session 2: July 11, 13, 18 and 20 Tuition Discount Code Parent/Guardian Contact Information #1 Please enter your information below. You will have to accept the terms and policies at the end of this form. Name (Last, First, M.I.) * Relationship * Driver's License State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Driver's License # * Same as Child's Address Same as Child's Address Address * Please enter your full street address as it is printed on your mail. * Contact Numbers Phone 1 * N/AHomeOfficeMobilePager Number 1 * Phone 2 N/AHomeOfficeMobilePager Number 2 Phone 3 N/AHomeOfficeMobilePager Number 3 Email Address Please fill out two email addresses below. We will use the primary email address for billing purposes and our newsletter. Primary Email Address * Re-enter Primary Email Address * Alternate Email Address Re-enter Alternate Email Address Employer Employer Employer Phone Number Employer Address Parent/Guardian Contact Information #2 Name (Last, First, M.I.) Relationship Driver's License State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Driver's License # Same As Child's Same as Child's Address Address * Contact Numbers Phone 1 N/AHomeOfficeMobilePager Number 1 Phone 2 N/AHomeOfficeMobilePager Number 2 Phone 3 N/AHomeOfficeMobilePager Number 3 Email Address Email Address Re-enter Email Address Employer Employer Employer Phone Number Employer Address
