First Name*

Last Name*

Email Address*

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First Name*

Last Name

Email Address*

Phone Number

Best Time to Contact You?

Comments

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Parent/guardian First Name*

Parent/guardian Last Name*

Parent/guardian Email Address*

Parent/guardian Phone Number

Child first and last name

Child Date Of Birth

Grade Level

Level: beginner, intermediate, advanced

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The program is currently full. Please fill out the form below to get on the waitlist.

First Name*

Last Name

Email Address*

Phone Number

Date Of Birth

Are you a green card holder? Yes No

How many years have you lived in the US?

Do you have an identified disability?

Level of English?

Refugee and/or asylee status

Thursday Evenings or Saturday Morning? Thursday evenings Saturday morning

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First Name*

Last Name*

Email Address*

Phone Number

Comments

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I understand my child will not be able to participate until the season is paid/ Entiendo que mi hijo(a) no podra participar hasta que paguemos la temporada

Yes/Si

No

Nombre del Estudiante/ Name of Student*

Fecha de Nacimiento/ Date of Birth*

Edad/ Age

2

3

4

5

Nombre del Padre/Madre o Tutor(a) / Parent or Guardian Information*

Telefono/ Phone Number

Email/ Correo Electronico*

Contacto de Emergencia/ Emergency Contact*

Domicilio/ Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Permisos / Permissions

Autorizo que mi hijo/a sea fotografiado/a para uso del campamento.

I give permission for my child to be photographed for camp use.

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First Name*

Last Name*

Email Address*

Phone Number

Comments

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First Name*

Last Name*

Email Address*

Phone Number

Comments

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