150 E Columbia Lane, Cocoa Beach, Fl 32931      Phone: 321-868-1980

Camp Enrollment Form

ATTN Parents of Summer Camp Students: AFTER you have called or emailed to confirm openings, please print, complete and sign this form and mail it to us with your deposit. 

First Name: ____________________________________________________ Male ______ Female _______

Last Name: _____________________________________ E-Mail: ____________________________________

Age ____________ Which week of Summer Camp will you be attending?: ________________________

Parent or Guardians Information:

Name:_________________________________________________________________________________

Relationship: ___________________________________________________________________________

Address: _______________________________________________________________________________

City _______________________________________________________ State _________ Zip __________

Home Phone: ______________________________ Cell Phone: ___________________________________

Other Emergency Contact:

Name: ______________________________________________ Relationship: _______________________

Phone Numbers:_________________________________________________________________________

Medical Information:

Allergies: _______________________________________________________________________________

Medical Problems _________________________________________________________________________

Medication: ______________________________________________________________________________

Notes: __________________________________________________________________________________

Student’s signature: ______________________________________________________Date: ____________

Parent or Legal Guardian:__________________________________________________Date:_____________