Call:954-384-1894
 
 

Please fill out a separate registration form for each child attending
*First Name : *Last Name :
*Current School Attending : *Sex :
*Date of Birth :
(Date format should be : mm/dd/yyyy).		 If possible, please place my child with :
(One mutual request will be granted)
*Age as of 6/1/2012: *Grade Entering For 2012/2013 School Year :
*Child's Physician : *Physician's Phone :
*May the school contact the physician if the parents cannot be contacted? :
*Allergies or Special Needs :
*Does your child have any problems that would affect his/her participation in any part of the camp program? :
*Father's Name : *Mother's Name :
*Home Address : *City :
*State : *Zip :
*Home Phone : *Cell Phone :
Mother's Work Phone : Father's Work Phone :
*Person to be contacted in case of illness, or emergency when the parents cannot be reached. These persons are additionally authorized to remove student from camp. If none, please indicate 'none' : None
*1 Person Name : *1 Person Home Phone :
*1 Person Cell Phone : *1 Person Relationship :
2 Person Name : 2 Person Home Phone :
2 Person Cell Phone : 2 Person Relationship :
3 Person Name : 3 Person Home Phone :
3 Person Cell Phone : 3 Person Relationship :