Camper's Name (first, last)

Parent(s) Name(s)

Address

City

Zip Code

Home Phone #

Parent Work Phone #

Parent Cell Phone #

Age

Grade

School Attending

List one person, who is attending Camp, you would like to be a room with. (not guaranteed)

Emergency Contact (other than parents)

Contact Home Phone #

Contact Cell Phone #

Space is Limited!!
Registration is not complete until payment has been recieved.
Payment must be made in person, or by mail. Online payment is not available.

For further information, call 925.210.9036