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2013 Summer Camp & Golf
Camper Information
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Postal Code:
Date of Birth
Member Number
Emergency Contact Information
Name
Relation to Child
Cell Phone

Name
Relation to Child
Cell Phone

Doctor's Name
Doctor's Phone Number

Hospital Preference
Hospital Phone Number

Health Insurance
Health Insurance Phone Number
Policy Number

Allergies
Medications
Permitted to Pick Up Your Child
Name
Relation
Program Information

Which session(s) would you like to attend?
Summer Camp
(select all that apply)
 June 18-21
 July 9-12
 July 30-August 2
 August 13-16
Golf Workshop
(select all that apply)
 June 18-21
 July 9-12
 July 30-August 2
 August 13-16

  

* Bold Fields are Required