Agape Life Summer Camp 8568 Laureldale Dr, Laurel, MD 20724 Phone: (301)-725-6525 or (301)-828-6664
2019 SUMMER CAMP PROGRAM APPLICATION
Email address *
CHILD #1
First Name
Your answer
Last Name
Your answer
Birth Date:
MM
/
DD
/
YYYY
Gender
Grade
Ethnicity:
CHILD #2
First Name
Your answer
Last Name
Your answer
Birth Date:
MM
/
DD
/
YYYY
Gender
Grade
Ethnicity:
CHILD #3
First Name
Your answer
Last Name
Your answer
Birth Date:
MM
/
DD
/
YYYY
Gender
Grade
Ethnicity:
Address:
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City
Your answer
State
Your answer
Zip Code
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Home Phone:
Your answer
Cell Phone:
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Work Phone:
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Emergency Contact Info (Contact Name):
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Phone Number
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Relationship to child:
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Allergies
If YES Please List
Your answer
PARENT
Authorized persons to pick up my child(ren) are : First & Last Name(s)
Your answer
Phone Number(s)
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.
Your answer
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