Parents of Summer Camp Students: Please Print a copy of this page, read and sign it

and then mail it to us with your deposit.

Please call or E-mail to confirm openings before you mail!! (321) 868-1980

First Name: __________________________ Male ______ Female _____

Last Name: _____________________________________ E-Mail: _______________________________

Age __________ Date Attending: ____________________

Parent or Guardians Information:

Name:______________________________________________________________

Relationship: __________________________________

Address: _____________________________ City _____________________

State _____________ Zip __________

Home Phone: ___________________________________

Day Phone: _____________________________________

Other Emergency Contact:

Name: _____________________ Relationship: __________

Phone #:______________________

Medical Information:

Allergies: ________________________________________

Medical Problems _________________________________

Medication: ______________________________________

Notes: ____________________________________________

*Used under license from Ron Jon Licensing, Inc.