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Summer Camp Waiver -Form Fill

Section One

Q1

Name of the Child*

First Name

Q2

Name of the Child*

Last Name

Q3

Name of the Parent/Guardian*

First Name

Q4

Name of the Parent/Guardian*

Last Name

Q5

Parent/Guardian's Phone Number

Q6

Parent/Guardian's Address

Street Address

Q7

Parent/Guardian's Address

Street Address Line 2

Q8

Parent/Guardian's Address

City

Q9

Parent/Guardian's Address

State / Province

Q10

Parent/Guardian's Address

Postal / Zip Code

Q11

Which program did you sign up for?*

Q12

Parent/Guardian Signature