Summer Camp Online Registration

Child's Information

Name, Age and Grade
First:	Last:	Age*:	Grade*:
			*As of 6-12-06

Date of Birth and Phone Number
Month:	Day:	Year:	Gender:	Phone:

Address
Street Address:	City:	State:	Zip:

Available Camp Sessions:$70 per week

My child would like to attend the following weeks of Summer Camp: (Check all weeks that apply but only one focus group per week. In Focus Groups marked with an * participants must be at least 11 years old)
Week One Focus Group Reading Swimming Basketball	Week Two Focus Group Reading Swimming Basketball
Week Three Focus Group Reading Swimming Basketball	Week Four Focus Group Reading Swimming Basketball
Week Five Focus Group Reading Swimming Basketball	Week Six Focus Group Reading Swimming Basketball
Week Seven Focus Group Reading Swimming Basketball	Week Eight Focus Group Reading Swimming Basketball

Medical Information

Child's Physician:	Phone:	Insurance Company:	ID Number:
Does your child have any medical concerns? Yes No
Please list any and all conditions and cocerns in the box below:

Emergency Contact Information

Name
Mother's Name:	Work Phone:	Home Phone:	Alternate Phone:
Father's Name:	Work Phone:	Home Phone:	Alternate Phone:
Emergency Contact Name & Relationship:	Work Phone:	Home Phone:	Alternate Phone:
In case of an emergency, who should we call first? (ie. mother-work or emergency contact-alternate) If you do not answer this qustion, then we will start with mother's work number and go from there.

Other Important Information

Please list other important information such as:

The first and last name of anyone who has permission to pick up your child. We will not let your child leave with anyone without prior approval.
Other information that was not fully covered by earlier questions.

Print and Sign

Please print and sign the following two forms and remit with your payment. Remember you must either mail or bring in your payment to the Civic Center within 5 business days of submitting this form for your registration to be valid.

Please Note The Following Information

Attention: This registration is not a real time registration process. Please indicate below if you would like to be contacted by phone or email to let you know that your registration is complete.

Phone Email Neither