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Applicant Name *

First Name

Last Name

Applicant Cellphone

Country

(###)

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Applicant Birthdate *

MM

DD

YYYY

Parent Name *

First Name

Last Name

Parent Cellphone *

Country

(###)

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Home Phone

Country

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Special Condition? *

Please note that we cannot accommodate all conditions. Failure to report a condition will result in expulsion from the camp.

The applicant has an allergy

The applicant has a learning disability

The applicant has a Medical Condition (autism, diabetes, epilepsy, or any chronic illnesses).

The applicant has Behavioral Needs/Tendencies

The applicant has Medication (Note we will store it for them but we will not administer the child MUST be able to self administer).

The applicant has no such conditions

Payment in Installments?

We would like to pay in installments