Camper's Name
First Name
Last Name
Please select All camp
❏
sessions in which your child
❏
is enrolling:
❏
Session 1: June 12 - 21
T-Shirt Size
❏
Adult Small
❏
Youth Small
❏
Adult Medium
❏
Youth Medium
❏
Adult Large
❏
Youth Large
❏
Adult X-Large
Grade (entering fall 2017)
Camper's Birthdate
Camper's E-mail
Session 2: July 10 - 19
Session 3: July 24 - August 2
Does the camper have any
allergies, chronic illness, or
medical conditions?
❍
NO
❍
YES
If yes, please describe any
such health conditions.
Is the camper prescribed an ❍
inhaler?
❍
NO
YES
If yes, please explain any
instructions for using the
inhaler.
Name
First Name
Last Name
Daytime Phone Number
Area Code
Phone Number
Area Code
Phone Number
Cell Phone Number
Parent's E-mail
Address
Street Address
Street Address Line 2
City
Postal / Zip Code
State / Province
Additional Emergency Contact
First Name
Last Name
Relationship to Child
Phone Number
Area Code
Phone Number
Area Code
Phone Number
Alt. Phone Number
SECRET WORD
List any other individuals
authorized to pick up your
child from camp activities.
Please separate names using
a comma (,).
Signature
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