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2017 Girls Summer Camp
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Preferred Name (Nickname)
Your answer
Grade in September 2017
*
Choose
4th
5th
6th
7th
Date of Birth
*
(mm/dd/yy)
Your answer
Gender
*
Female
Male
Required
Current School
*
Your answer
What week(s) will you attend?
*
Week 1
Week 2
Week 3
(optional date only for Week 3 Campers) July 3
Required
Will you need After Care?
*
Yes, Week 1
Yes, Week 2
Yes, Week 3
No, I will not be needing After Care
Required
Will you need Before Care?
*
Yes, Week 1
Yes, Week 2
Yes, Week 3 (Available only for July 5-7)
No, I will not be needing Before Care
Required
Please list the first and last name(s) of persons who are allowed to pick up your daughter.
*
Write n/a if only Parent 1 & 2 are allowed to pick up your daughter.
Your answer
Name of Parent/Guardian #1
*
Your answer
Parent/Guardian #1 Phone
*
What is the best number to reach you?
Your answer
Parent/Guardian #1 Email
*
Your answer
Name of Parent/Guardian #2
Your answer
Name of Parent/Guardian #2 Phone
What is the best number to reach you?
Your answer
Parent/Guardian #2 Email
Your answer
How did you hear about Girls Summer Camp?
*
Attended last summer
Friend
Word of mouth
Daughter who attends JMSG
JMSG website
Internet search for "camp."
Berkeley Parents Network
Other:
Required
Select a t-shirt size
*
Included in the cost of camp
Choose
Youth Small
Youth Medium
Youth Large
Youth Extra Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Emergency Contact Information
In case we are unable to reach you, please list emergency contacts for your daughter.
Emergency Contact (1)
*
Your answer
Relation (1)
*
Your answer
Phone (1)
*
Your answer
Emergency Contact (2)
*
Your answer
Relation (2)
*
Your answer
Phone (2)
*
Your answer
Emergency Contact (3)
Your answer
Relation (3)
Your answer
Phone (3)
Your answer
Physician Name
*
Your answer
Physician Phone
*
Your answer
Dentist Name
*
Your answer
Dentist Phone
*
Your answer
Please take my daughter to the following hospital
*
Your answer
Include known allergies, medical issues, and medications. Write your daughter's name on every bottle of medication sent to camp.
*
Write n/a if not applicable.
Your answer
Parent Signature
*
Please write the first and last name of the person completing this form.
Your answer
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