Registration Form

pd _______



Name: ________________________________________

Address: ______________________________________

Phone: _______________________________________

Birthdate: _____________________________________

Health Card #: _________________________________

Parents or Guardians Name: _______________________

Emergency Contact: _____________________________

Special Medical Condition, Diet, or Known Allergies:

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Camp

_____ Sports, Games & Adventure Camp July 19 - 23

_____ Water Mania & Outdoor Adventure July 26 - 30

_____ Mystery Camp Aug. 9 - 13

_____ Before & (or) After Care Required

I _________________________________________ give my permission for ________________________________________

to attend and participate in the summer camp program chosen above.

Parent's Signature: _______________________________