Summer Camp Application
For ACT and CLYP camps at St. James Presbyterian Church
Email address *
Camper Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Grade Level *
School *
Your answer
Extracurricular activities
Your answer
Medications taken *
Your answer
Medication frequency *
Your answer
Food and Medication allergies *
Your answer
Physician's Name *
Your answer
Physician Phone number *
Your answer
Insurance company, group and policy #s
Your answer
Guardian 1 Name *
Your answer
Guardian 1 Address *
Your answer
Guardian 1 Phone number *
Your answer
Guardian 2 Name *
Your answer
Guardian 2 Address *
Your answer
Guardian 2 Phone number *
Your answer
Who is the custodial parent? *
How did you hear about ACT/CLYP summer camp? *
Interested in carpooling or need transportation *
Emergency contact 1 *
Your answer
Emergency contact 1 phone *
Your answer
Emergency contact 1 relationship *
Your answer
Emergency contact 2 *
Your answer
Emergency contact 2 phone *
Your answer
Emergency contact 2 relationship *
Your answer
Alternate Pickup 1 Name *
Your answer
Alternate Pick up Phone number *
Your answer
Alternate Pickup 2 Name *
Your answer
Alternate Pickup 2 Phone number *
Your answer
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