Camper Registration
Please fill out this form for Camper Registration
* Required
Email address
*
Your email
Camper First Name
*
Your answer
Camper Last Name
*
Your answer
Street Address, Unit (if applicable)
*
Your answer
City, State
*
Your answer
Zip Code
*
Your answer
Telephone Number (xxx-xxx-xxxx)
*
Your answer
Mother/Parent Name
*
Your answer
Mother/Parent Day Phone Number (xxx-xxx-xxxx)
*
Your answer
Father/Parent Name
*
Your answer
Father/Parent Day Phone Number (xxx-xxx-xxxx)
*
Your answer
Additional Emergency Contact Name
*
Your answer
Additional Emergency Contact Relationship
*
Your answer
Additional Emergency Contact Telephone Number (xxx-xxx-xxxx)
*
Your answer
Camper Date of Birth
*
MM
/
DD
/
YYYY
Camper Gender
Male
Female
Other:
Clear selection
Camper Communication
*
Oral
TC
ASL
Cochlear Implant
Required
Camper T-shirt Size
*
Child Small
Child Medium
Child Large
Child XL
Adult Small
Adult Medium
Adult Large
Adult XL
Other:
Would you like pickup from Boys and Girls club between 1 and 5 pm?
*
Yes
No
How did you hear about Sertoma?
Your answer
Camper registration is $50. How would you like to pay?
*
Cash/Check (please mail to LSL CPAs, c/o Grady Tarplee, 1611 E. 4th St, Ste 200, Santa Ana, CA 92701
Debit/Credit/Paypal (please visit the "Camper Registration" page and follow the instructions on payment)
I won a free camper registration at 2018's camp (please bring a copy of your award the first day of camp)
Please chose this option to request a scholarship. Scholarships will be confirmed via email.
Send me a copy of my responses.
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