AGAPE LIFE MINISTRIES,INC. 2018 SUMMER CAMP PROGRAM
2018 SUMMER CAMP PROGRAM APPLICATION FORM
Duration: Monday, June 18, 2018 to Friday, August 31, 2018
Address: 8574 Laureldale Dr, Laurel, MD 20724
Email address *
Child 1 FIRST & LAST NAME *
Your answer
DATE OF BIRTH *
MM
/
DD
/
YYYY
GENDER *
Required
GRADE *
Your answer
Child 2 FIRST & LAST NAME *
Your answer
DATE OF BIRTH *
MM
/
DD
/
YYYY
GRADE *
Your answer
GENDER *
Required
Child 3 FIRST & LAST NAME *
Your answer
DATE OF BIRTH *
MM
/
DD
/
YYYY
GRADE *
Your answer
GENDER *
Required
Ethnicity *
Required
STREET ADDRESS *
Your answer
CITY *
Your answer
STATE *
Your answer
ZIP CODE *
Your answer
HOUSE PHONE NUMBER *
Your answer
CELL PHONE NUMBER *
Your answer
WORK PHONE NUMBER *
Your answer
EMERGENCY CONTACT INFORMATION
CONTACT: (First & Last Name) *
Your answer
PHONE NUMBER *
Your answer
RELATIONSHIP TO CHILD *
Your answer
ALLERGIES: *
Required
IF 'YES' PLEASE LIST *
Your answer
SPECIAL NEEDS? *
Required
IF 'YES' PLEASE LIST
Your answer
PARENT *
AUTHORIZED PERSON (S) TO PICK UP MY CHILD(REN) *
IF 'YES' PLEASE LIST THEIR NAME(S) *
Your answer
FIRST & LAST NAME(S) {Separate with (/) }
Your answer
FIRST AUTHORIZED PERSON PHONE NUMBER
Your answer
SECOND AUTHORIZED PERSON PHONE NUMBER
Your answer
THIRD AUTHORIZED PERSON PHONE NUMBER
Your answer
FOURTH AUTHORIZED PERSON PHONE NUMBER
Your answer
If under 18 years of age please notify staff. My signature authorizes my child to be picked up only by the persons I have listed on this form unless otherwise notified in writing.
Parent/Guardian: FIRST & LAST NAME *
Your answer
SIGNATURE (INITIALS) *
Your answer
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