Summer Camp Registration

Parent's Information

*Last Name
*First Name
*Address
*City
*State
*Zip
*Personal #
*Work #
*Your Email
*Emergency Contact
*Emergency #

Student Information:


*Child Name

*Age

*Grade

*School

*Date of Birth

Medical Information:

*Family Physician
*Physician's #
Allergies
Special Concerns
I would like to volunteer to:
 Help Prepare Snacks

Please note the following fees:

One (1) Student is $30
Two (2) Students in the same family is $50
Three or more (3+) Students in the same family is $65