Enrollment Form


	Please Mail all correspondences to: 150 E. Columbia Ln. Cocoa Beach, Fl. 32931 Parents of Summer Camp Students: Please Print a copy of this page, read and sign it and then mail it to us with your deposit. Please call or E-mail to confirm openings before you mail!! (321) 868-1980 First Name: __________________________ Male ______ Female _____ Last Name: _____________________________________ Age __________ Date Attending: ____________________ Parent or Guardians Information: Name:______________________________________________________________ Relationship: __________________________________ Address: _____________________________ City _____________________ State _____________ Zip __________ Home Phone: ___________________________________ Day Phone: _____________________________________ Other Emergency Contact: Name: _____________________ Relationship: __________ Phone #:______________________ Medical Information: Allergies: ________________________________________ Medical Problems _________________________________ Medication: ______________________________________ Notes: ____________________________________________