2019 Summer Camp Registration

Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Name

First Name

Last Name

Phone *

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Phone *

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Does your child have a history of any of the following?

Hay Fever

Heart Murmur or Defect

Anemia

Cystic Fibrosis

Seizures or Epilepsy

Diabetes

Dietary Disorders

Asthma

Other