Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Parent's Phone # *

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone #: *

(###)

###

####

Child's Physician *

First Name

Last Name

Phone #: *

(###)

###

####

Camp Weeks *

Select all that apply

Week #1 - (6/9 - 6/13)

Week #2 - (6/16- 6/20)

Week #3 - (6/23 - 6/27)

Week #4 - (6/30- 7/2) Half Week

Week #5 - (7/7- 7/11)

Week #6 - (7/14 - 7/18)

Week #7 - (7/21 - 7/25)

Week #8 - (7/28 - 8/1)