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Section 1: Camper Information
First Name
  Last Name
  Birthdate
  Gender
Male Female
Address
  City/State/Zip
  Primary Phone
  Second Phone
Mother's Name
  Father's Name
  Mom's Daytime Phone
  Dad's Daytime Phone
    Email:                                        How did you hear about us:  

Additional Information About your Camper
Allergies
Gluten Free: No Yes
Dairy/Casein Free: No Yes
Other food concerns:
Is your child toilet trained? Yes
Please let us know if there is any additional information we may need to make camp as comfortable and safe for your child as possible. This includes any behavior, diet, special updates, etc information...
Section 2: Medication Information (if applicable)
Name of Medication
  Dosage
  Dates Administered
from
 
to
Specific time(s) and additional instructions
             
Section 3: Registration and Payment Information
My child will be attending on:
Monday, June 24  Tuesday, June 25  Wednesday, June 26  Thursday, June 27  Friday, June 28
One t-shirt will be supplied with registration. Additional t-shirts are available for $6 each.
Quantity: Size:
days of camp @ $60 per day:
  Payment type
  Card Type (if using cc)
cost for t-shirts ($6 each, after the 1st):
 

Card Number:
    

CCV
TOTAL OWED:
  Billing Zip
  Exp. Date

Please type your name to verify registration: