Child's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact Information *

(###)

###

####

Child's Gender *

Boy

Girl

Parent/Guardian Name *

First Name

Last Name

Saturday Lunch Choice *

Please make ONE selection PER person

Peanut Butter & Jelly Sandwich

Cold Deli Sandwich

Hot Dog

My child needs a mentor *

Your registration is not complete if your student does not have a mentor. We will do our best to assign a mentor but if one cannot be assigned you will be refunded your registration fee.

Yes

No

Mentor Information

First Name

Last Name

Address

If different from above address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Have you been convicted of a felony? *

All information will be kept confidential and is only used for the sole safety purposes of all camp attendants.

yes

no

Authorization for background check *

By checking this box, you agree to be subject to a background check performed by DWC and will provide your driver's license and or social security number if asked.

Yes, I agree

No, I do not agree