Admin
 
Camper Application Form
Please fill out each field, and enter n/a for those fields that do not apply to you.
First Name
Last Name
Address
City
State
Zip Code
Phone  xxx xxx-xxxx
Sex
Age
Birth Date  mm/dd/yy
Sessions Desired
Parent/Guardian 1 (Father) - First Name
Last Name
Work Phone  xxx xxx-xxxx
Home Phone  xxx xxx-xxxx
Cell Phone  xxx xxx-xxxx
Parent/Guardian 2 (Mother) - First Name
Last Name
Phone  xxx xxx-xxxx
Emergency 1 First Name
Emergency 1 Last Name
Emergency 1 Address
Emergency 1 Phone  xxx xxx-xxxx
Emergency 2 First Name
Emergency 2 Last Name
Emergency 2 Address
Emergency 2 Phone  xxx xxx-xxxx

If you have any comments on your child's areas of interest,
behavior patterns, etc. that would help make "Camp Smile"
more enjoyable for him/her, please note them here
Special Restrictions
Child's shirt size
Bus Transportation Needed?
If yes, what will the pick up/drop off address be and who will be the contact at that address?
Contact First Name
Contact Last Name
Contact Address
Contact City
Contact State
Contact Zip Code
Contact Phone  xxx xxx-xxxx
Contact Cell Phone  xxx xxx-xxxx
Captcha:
 
 
 
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