Summer Camp Registration Form

Grade completed in 2008:	First Second Third Fourth Fifth Sixth
Name:(First, Middle, Last)
Student's Address:
City:
State:
Zip Code:
Student's Home Phone:
Birth Date:
Age:
Student Lives With:	Mother Father Stepfather Stepmother
Parents are:	Married Single Separated Divorced Mother or Father Deceased
School last attended:(please include Name of school, address, phone,and child's last teacher)
Father's name:
Father's phone number:
Father's address: (If different from student)
Father's employer: (please include Address,and Phone number)
Mother's name:
Mother's phone number:
Mother's address:(If different from child)
Mother's employer:(please include address and phone number)
Name of Family Church:
Bill to:(Name and address)
Email Address:

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