Name Parent/Guardian 1 *

First Name

Last Name

Cell Phone: Parent/Guardian 1 *

(###)

###

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Work Phone: Parent/Guardian 1 *

(###)

###

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Name: Parent/Guardian 2

First Name

Last Name

Cell Phone: Parent/Guardian 2

(###)

###

####

Work Phone: Parent/Guardian 2

(###)

###

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Additional Caregiver

If applicable - Nanny, grandparent, etc.

First Name

Last Name

Additional Caregiver Phone

(###)

###

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Child's Name *

First Name

Last Name

Child's Sex *

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone

(###)

###

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Does Child Receive Special Services *

No

Speech

OT

PT

Other

Summer Camp Program (please select) *

Summer Camp runs June 29-Aug 6, in 4-day sessions: Monday-Thursday, from 9am - 11:15/30am. Your child may attend any of 1 - 6 weeks. Please select from the below:

Week 1: June 29-July 2

Week 2: July 6-July 9

Week 3: July 13-July 16

Week 4: July 20-July 23

Week 5: July 27th-30

Week 6: Aug 3-Aug 6

Child 2 Name

First Name

Last Name

Child 2 Sex

Male

Female

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 2 Home Phone

(###)

###

####

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other