Summer LAF - Youth Camps Registration

--------------------------------- Youth Camps Registration Form ---------------------------------

Student First Name	*
Student Last Name	*
Date of Birth	*
Address1	*
Address2
City	*
State	*
Zip	*
Telephone	*
Cell Phone
Email	*
Parent/Guardian Name	*
Emergency Contact	*
Emer. Contact Telephone	*
Grade in Fall 2008	*
Name of Current School
Special Health Conditions (if any, please explain)
Dietary Restrictions (if any, please explain)

Registering For:
Sessions	*	Session 1 (June 15 thru June 26) Session 2 (July 29 thru July 10) Session 3 (July 27 thru August 7) Session 4 (July 27 thru August 7)
Blocks	*	Full Day (9:00am - 4:00pm) Moring Block (9:00am - 12:00pm) Afternoon Block (1:00pm - 4:00pm) Early Arrival (8:00am - 9:00am) After Care (4:00pm - 6:00pm)

Would you like school provided lunch?	*	Yes No
Would you like school provided transportation?	*	Yes No
Would you like to register for after-care (3:15pm - 6:00pm)?	*	Yes No

Payment Type		Check MasterCard Visa
Credit Card Number
Exp. Date

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