Summer Camp Registering Form

*Last Name

*Home Address

*First Name(s)

*Postal Code

* School Year

*Birth Date

* Male/Female

*Telephone

*E-mail Address

*Last Name

1 Cell Phone #

*First Name(s)

*E-mail Address

*Last Name

2 Cell Phone #

*First Name(s)

*E-mail Address

Please Enter Your Credit Card Information

First Name:

Last Name:

Card Type:

Total Fees Due with Application:

Credit Card Number:

Expiration Date:

Card Verification Number:

(On the back of your card, find the last 3 digits)

*A 3% processing fee will be added to payments made by credit card.

Name of Doctor

Telephone

Address

Will your child require any medication during camp? If yes, please label any medication brought with name and dosage and please
specify below:

Does your child have any allergies? If yes please specify below:

Does your child have any dietary requirements? (e.g. Vegetarian)

Please detail any other information you feel it may be appropriate for us to know including any conditions or family situations that
would require your child to receive extra care:

Please detail any medical condition(s) your child may have:

Emergency Contacts

1.Name

Telephone

2.Name

Telephone

Date of Last Vaccination Injection

By submitting below I certify that this information I have submitted is accurate and complete.