GENERAL INFORMATION

Camper Last Name:

Camper First Name:

Parent Name:

Home Phone:(555-555-5555)

Address:

City:

State:
AK AL AR AZ CA CO CT DC DE FL GA NM HI IA ID IL IN KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:

School Attend:

Grade (in fall):
4 5 6 7 8 9 10
Date of Birth: (1/1/1999)

Sex:
M F
T-shirt Size:
Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large Adult XXL
E-mail Address:

How did you hear about the camp?:
Postcard Brochure Newspaper Internet Television Other
Please explain "other":

STEP 2
MEDICAL INFORMATION

Parent/Guardian Name:

Home Phone:(555-555-5555)

Cell Phone:(555-555-5555)

Work Phone:(555-555-5555)

Family Physician:

Physician Phone:(555-555-5555)

Insurance Company:

Policy Number:

Policy in Name of:

Allergies, please list:

Camper's Last Tetanus Shot Date:(1/1/1999)

Any medications or medical condition camp should be aware of?:

I hereby certify that my son/daughter/ward is in good health and may participate in all camp activities. I will not hold Santa Monica College or NLAEA responsible in the event of an accident or injury as a result of his or her participation. I also give permission for my child/ward to be given emergency treatment at a local hospital.
Parent/Guardian Signature:

Payment type:
Credit Card Online Credit Card via Mail Check via Mail Money Order via Mail