*Childs Name:
Birth date:
What name does your child go by:
Gender:	Male Female
Street Address:
City/ State/ Zip:
Home Phone #:
FATHER'S Name:
Work Phone#:
Cell Phone #:
Occupation:
MOTHER'S Name:
Work Phone #:
Cell Phone #:
Church you attend:
EMERGENCY INFO: List two other people we may contact in case of an emergency:
Name/ Relationship:
Phone #:
Second Name/ Relationship::
Second Phone #:
Child's Doctor & Phone #:
List any medical problems (allergies, asthma, etc.):
Is there anything about your child, family, or home situation you feel we should know, so we may bet:
I wish to enroll my child for Summit's Camp:	I agree I disagree
I will pay the non-refundable enrollment fee.:	I agree I disagree
Without receipt of payment, the camp program has the right to give my child's spot to another:	I understand and agree I disagree
Late fee of $5 for the first 5 minutes and $1 for each additional minutes are charged:	I understand and agree I do not agree
A $25 fee will be charged for returned checks.:	I understand and agree I do not agree