Camper Registration
Please fill out this form for Camper Registration
Email address *
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
Camper Communication *
Required
Camper T-shirt Size *
Would you like pickup from Boys and Girls club between 1 and 5 pm? *
How did you hear about Sertoma?
Your answer
Camper registration is $50. How would you like to pay? *
Submit
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