Camper Registration
Please fill out this form for Camper Registration
Email address *
Camper First Name *
Camper Last Name *
Street Address, Unit (if applicable) *
City, State *
Zip Code *
Telephone Number (xxx-xxx-xxxx) *
Mother/Parent Name *
Mother/Parent Day Phone Number (xxx-xxx-xxxx) *
Father/Parent Name *
Father/Parent Day Phone Number (xxx-xxx-xxxx) *
Additional Emergency Contact Name *
Additional Emergency Contact Relationship *
Additional Emergency Contact Telephone Number (xxx-xxx-xxxx) *
Camper Date of Birth *
Camper Gender
Clear selection
Camper Communication *
Camper T-shirt Size *
Would you like pickup from Boys and Girls club between 1 and 5 pm? *
How did you hear about Sertoma?
Camper registration is $50. How would you like to pay? *
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