Summer Camp Application 2020

School of Choice*

Child's Name*

First Last Suffix

Full name as listed on the birth certificate

Child's Date of Birth*

MM

DD

YYYY

Gender*

Language(s) Spoken at Home

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Doctor's Information*

Street Address Address Line 2 City State ZIP Code

Doctor's Phone #*

Are you eligible for Urban League or any other subsidy assistance?

Parent/Guardian #1 Information

Name*

First Last

Relationship to Child*

Daytime Phone*

Mobile Phone

Email*

Name

First Last

Relationship to Child

Daytime Phone

Mobile Phone

Email

Parent Certification*

I agree to the privacy policy.

I certify that the statements made by me in this application are true, complete and correct to the best of my knowledge.

Name*

First Last

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