Registration Form

Number of children you want to sign up for Camp ADEP:(Required)

#1 Child Name(Required)

First Last

#1 Child Date of Birth(Required)

#1 Child Current Age(Required)

#1 Child - Any Allergies?(Required)

Yes

Please indicate all allergies:(Required)

#2 Child Name(Required)

First Last

#2 Child Date of Birth(Required)

#2 Child Current Age(Required)

#2 Child - Any Allergies?(Required)

Yes

Please indicate all allergies:(Required)

#3 Child Name(Required)

First Last

#3 Child Date of Birth(Required)

#3 Child Current Age(Required)

#3 Child - Any Allergies?(Required)

Yes

Please indicate all allergies:(Required)

Any Restrictions/Notes:(Required)

Parent Name(Required)

First Last

Parent Phone Number(Required)

Parent Email(Required)

2nd Contact Name(Required)

First Last

2nd Contact Relation(Required)

2nd Contact Phone Number(Required)

Child Address(Required)

Street Address Address Line 2 City State ZIP Code

Name(s) of Individuals AUTHORIZED to pick up:(Required)

Name(s) of Individuals NOT AUTHORIZED to pick up:(Required)

Signature