Summer Day Camp Registration

Summer Day Camp Registration:

Please fill out all information completely

Child's First Name:
Child's Last Name:
Home Phone:
Cell Phone:
Email Adress:
Child's Gender:	Male Female
Child's Date Of Birth:
Last School Grade Completed:
Street Adress:
City:
State:
Zip Code:
Parent/Guardian First Name:
Parent/Guardian Last Name:
Emergency Contact (1) Name:
Emergency Contact (1) Phone:
Emergency Contact (2) Name:
Emergency Contact (2) Phone:
Any Additional Information:
Does this child have any disabilities, handicaps, or present injuries or limitations, allergies, hemophilia, heart conditions, history of respiratory illness, or any other significant medical condition?	Yes No
If above answer is yes, please explain:

Please select which weeks your child plans to attend, along with time planned to stay (half day, full day, etc...)	June 14th-18th Florida June 21st-25th North Carolina June 28th-July 2nd Texas (Vacation Bible School) July 5th-9th Arizona July 12th-16th Hawaii (Soccer Camp) July 19th-23rd Alaska (Basketball Camp) July 26th-30th Washington August 2nd-6th Maine August 9th-13th California (Music Camp) August 16th-20th Kansas

*Before and After Care when attending another camp on site is $100.00

plus the cost of the other camp*

**You must fill out a seperate registration if attending VBS, Sports Camp, or Music Camp**