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FUSION Program Summer Day Camp 2008
Online Registration Form

Date Cost Total
July 28 - August 8, 2008 x $450.00 per camper =
Additional Services    
Precare/Aftercare x $100.00 per camper =
  Balance Due
Method of Payment  
Check Credit Card (via PayPal only) Cash

Camper(s) Information

1. Name
Age Male Female

Does your child have any allergies, fears, disabilities, or other special needs that the program director should know about?

 
2. Name
Age Male Female

Does your child have any allergies, fears, disabilities, or other special needs that the program director should know about?

 
3. Name
Age Male Female

Does your child have any allergies, fears, disabilities, or other special needs that the program director should know about?

 
Medical Information
Doctor's Name
Phone Number:

Family Information

Primary Family Member Contact
Name
Address, City, and Zip
Home Phone Work Phone
Cell Phone/Pager Email
   
Other Family Member Contact  
Name
Address, City, and Zip
Home Phone Work Phone
Cell Phone/Pager Email

Emergency Contact

Name
Address, City, and Zip
Home Phone Work Phone
Cell Phone/Pager Email

How Did You Hear About Us? (please check all that apply)

iPride Event
Advertisement
Website
Listserv
Word of Mouth
Camp Informational Fair
Other Community Organization/Event
Other (please specify):

Please provide us with your name and email address, so we may contact you:

Name:

Email Address: