Wufoo

Wizards & Wonders Enrollment Form

Summer Bible Camp for Grades 1 - 6
July 28 - August 1, 2008

Camper's Name * First Last
Birthdate * / MM / DD YYYY
Grade in Fall 2008
School Currently Attending
Parent/Main Contact * First Last
Email
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Cell Phone - (###) - ### ####
Work Phone - (###) - ### ####
Emergency Contact # 1
Name of Adult Contact * First Last
Relationship to the child *
Home Phone * - (###) - ### ####
Work Phone - (###) - ### ####
Cell Phone - (###) - ### ####
Emergency Contact - #2
Name of Adult Contact First Last
Relationship to the child
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Cell Phone - (###) - ### ####
Medical Information
Allergies / Special Health Considerations
Physician's Name *
Phone Number * - (###) - ### ####
Insurance Company
Policy Number
Hospital / Clinic Preference
Extended Daycare (available at an extra cost)
Please indicate schedule needed
Payment of fees
Payment type
Do Not Fill This Out