Evergreen Summer Camp
Summer Camp begin at 8:30am and end at 2:30pm Monday-Thursdays.  Saltsburg Club dates:  June 9-July 3 and meet at the Salt Center.  Blairsville Club dates:  July 7-July 31 and meet at the Blairsville Community Center. Camp is for students in grades 1-6.
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Childs First Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Childs Last Name *
Grade Level for the 24-25 School Year: *
In which school district do you live? *
Race *
Gender *
Best Parent/Guardian Email Address  *
Child's Physical Street Address *
Ex: 501 East Pike Rd.
PO Box:
If none, please skip this question
City/Municipality *
Zip Code *
Parent/Guardian Phone Number  *
Is the number provided a cell phone or landline? *
Household Members *
Please place a checkmark next to all household members who live with the child in the primary residence:
Required
Parent Guardian 1: Full Name *
Parent Guardian 1: Phone # *
Parent Guardian 1: Street Address
If different than above.  If not, please skip this question
Parent Guardian 1: Date of Birth *
month/day/year
Parent/Guardian 2:  Full Name 
If no 2nd Parent/Guardian, please skip this and the related questions
Parent/Guardian 2:  Phone #
Parent/Guardian 2:  Street Address
If different than above
Parent/Guardian 2:  Date of Birth
month/day/year
Please list the full names, relationship to the registered child, age, of all people living with the child at the primary residence *
EX:  Joan Smith - Sister - 17 
Are any of the child's household members disabled?   *
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