FUSION Program Summer Day Camp 2008
Online Registration Form

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

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: