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Name Gender Grade entering Birthdate
Address City State Zip
E Mail Home Phone 2nd Phone

Check preferred program:

Week one girls grades 4- 12
Overnight ($525.00) Day camper($425.00)
Early enrollment Overnight ($505.00) Early enrollment Day camper($405.00)

Week two boys grades 4 - 12
Overnight($525.00) Day camper($425.00)
Early enrollment Overnight($505.00) Early enrollment Day camper($405.00)

Requested Roommate
Must be reciprocal. Please ask requested roommate to request you as well.

Guardians Name Relationship
Home phone Work phone

Emergency contact; Name Emergency contact; Phone
Medical Insurance Company Policy #
Name of policyholder
Instructions regarding insurance

Please notify notify us ASAP of any unusual medical conditions or dietary requirements. All medical and disclaimer forms will be completed at time of registration. Updated insurance information will also be completed at this time.

All fields are manditory, please make sure they are complete.
    
All information will be treated as confidential.