SUMMER CAMP 2007

                                                         Student Registration Form
Child’s Information
Last, First Name:
Gender: Language:
Date of Birth: Race/Ethnicity (optional):
School Attending Grade Room #Class

Primary Guardians’ Information
Last, First Name: RelationShip:
Date of Birth: Birth Place:Language:
Home Address:
City: State: Zip Code:
Home Phone: Mobile Phone:
E-mail address:Ocupation:
Company Name:
Work Phone: ext/dept.

Other Guardian’s Information
ast, First Name: RelationShip:
Date of Birth: Birth Place:Language:
Home Address:
City: State: Zip Code:
Home Phone: Mobile Phone:
E-mail address:Ocupation:
Company Name:
Work Phone: ext/dept.

Emergency Contact
Person’s Name:Phone Number: