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FUSION Program Summer Day Camp 2010
Online Registration Form

CAMPER INFORMATION
First Name: Last Name:
Nickname:
Date of Birth:

Age of camper while at FUSION:

Number of years at FUSION:
Camper identifies as:
Camper identifies as:

Does the camper have any allergies, disabilities, or other special needs? Yes No
Please specify:
Does the camper need Precare/Aftercare? Yes No
Does the camper have a sibling who is also registering for the summer camp? Yes No

FAMILY INFORMATION
Primary Address for All Correspondence
Address:
City: State: Zip:
Email:
 
Primary Parent Contact
First Name: Last Name:
Daytime Phone: Cell Phone:
 
Secondary Parent Contact
First Name: Last Name:
Daytime Phone: Cell Phone:

EMERGENCY CONTACT
First Name: Last Name:
Phone:
Relationship to Camper:

HOW DID YOU HEAR ABOUT US? (please check all that apply)

Advertisement
Website
Email
Brochure
Word of Mouth
Camp Informational Fair
Other (please specify):

I would like my child to attend FUSION because:

METHOD OF PAYMENT:

Note: $50 non-refundable deposit due at registration. Balance due by June 14th, 2010.
This deposit holds your camper's place and avoids being bumped to the wait list.

Please enter the security code below:

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