Parent/Guardian's Name *

First Name

Last Name

Primary Phone *

(###)

###

####

Work/Cell (Mother/Guardian)

(###)

###

####

Work/Cell (Father/Guardian)

(###)

###

####

Family Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student 1's Name *

First Name

Last Name

Student 1's Date of Birth *

MM

DD

YYYY

Student 1's Session

Please choose ONE session in which your child will be participating. *ALL classes will be filled on a first come, first serve basis*

WEEK 1 MORNINGS (1st-2nd Grade)

WEEK 1 AFTERNOONS (3rd-4th Grade)

WEEK 2 MORNINGS (1st-2nd Grade)

WEEK 2 AFTERNOONS (3rd-4th Grade)

WEEK 2 MORNINGS (5th-6th Grade)

WEEK 2 AFTERNOONS (5th-6th Grade)

CAMP Save-a-Life (Hope Campus)

CAMP Save-a-Life (Texarkana Campus)

I give my child permission to participate in water play that may result in wet clothing. *

Yes

No

Student 2's Name

First Name

Last Name

Student 2's Date of Birth

MM

DD

YYYY

Student 2's Session(s)

Please choose ONE session in which your child will be participating. *ALL classes will be filled on a first come, first serve basis*

Week 1 MORNINGS (1st-2nd Grade)

Week 1 AFTERNOONS (3rd-4th Grade)

Week 2 MORNINGS ( 1st-2nd Grade)

Week 2 AFTERNOONS (3rd-4th Grade)

WEEK 2 MORNINGS (5th-6th Grade)

WEEK 2 AFTERNOONS (5th-6th Grade)

CAMP SAVE A LIFE (Hope Campus)

CAMP SAVE A LIFE (Texarkana Campus)

I give my child permission to participate in water play that may result in wet clothing. *

Yes

No