Crossroads CYC

Day Camp 2011

Camper First Name *

Last Name *

Choose Week(s) * June 13th-17th June 20th-24th

Birthdate *

Gender * Female Male

Grade Entering *

Camper Age *

Street Address *

City *

Zip *

Email *

Home Phone *

Work

Cell

Emergency Contact Name *

Emergency Contact Number *

Camper Swimming Level *

Camper Health (Medication / Allergies)

I would like a $10 Camp T-shirt * Yes No

T-shirt Size

I give Crossroads permission to use my child's photo in any Crossroads publications * Yes No

Parent / Guardian Names *