Childs Name

Address

City

 

Zip Code

Email

Age

Date of Birth

Parents Name

Home Phone

Cell Phone

Emergency Contact Name

Emergency Contact Relation

Emergency Contact Phone

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8

Additional Weeks of Camp

Option Number

Number of Days

Attending Camp with

Form Submitted By

Promotional Code

Credit Card #

EXP

Name on Card

Signature