NORTHWEST COMMUNITY CENTER
SUMMER
CAMP REGISTRATION FORM
2004
Cost
for 2004 10-week camp: $ 250.00*
*Discounts
available for families with multiple children
*Assistance
also available through YWCA Child Care Solutions program for eligible
families
DATE:
__________________
Please
fill in all information. Please print in ink.
CHILD INFORMATION:
NAME:
_____________________________/ _________________________/ (____________)
Last First Sex
ADDRESS:______________________________________zip__________________________
PHONE:
_________________________________BIRTHDATE:_________________________
AGE
________ Is your child on prescription
medicine? Y N
CHILD INFORMATION:
NAME:
_____________________________/ _________________________/ (____________)
Last First Sex
ADDRESS:______________________________________zip__________________________
PHONE:
_________________________________BIRTHDATE:_________________________
AGE ________
Is your child on prescription medicine? Y N
CHILD INFORMATION:
NAME:
_____________________________/ _________________________/ (____________)
Last First Sex
ADDRESS:______________________________________zip__________________________
PHONE:
_________________________________BIRTHDATE:_________________________
AGE ________
Is your child on prescription medicine? Y N
PARENT INFORMATION:
NAME:
_________________________________ WORK PHONE: ________________________
ADDRESS:_____________________________________________________________________
CIYT/STATE/ZIP:_______________________________________________________________
EMAIL
ADDRESS:______________________________________________________________
PLACE
OF EMPLOYMENT: ______________________________________________________
(IDPA
NUMBER IF APPLICABLE) ________________________________________________
EMERGENCY
CONTACTS:
1) ______________________________________________________________________________
NAME PHONE
2) ______________________________________________________________________________
NAME PHONE
3) ______________________________________________________________________________
NAME PHONE
___________________________________________________
Signature of parent
If there is any other information you would like us to know about your child (ren) or yourself, please let us know:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The
need any special accommodations please call the
Amount of Check/Payment enclosed: $_____________________________Checks/Money Orders make payable to: Northwest Community Center
Return Registration to:
Northwest Community Center Summer camp
(815) 964-6885)
Photos from Summer Camp 2003 can be seen on our website: Norhtwestrockford.org
ENOY THE SUMMER AT NORTHWEST!!!