CAMPER INFORMATION

First Name

Last Name

Gender:       Male Female

Home Telephone

(xxx-xxx-xxxx)

Address

City

State

ST AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA MN MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY OTHER   Zip      

School

Grade

Date of Birth

//

Age

PARENT INFORMATION

Parent 1 Name:

Employer:

Business:

Cell Phone:

Parent 2 Name:

Employer:

Business:

Cell Phone:

With whom does the Child Live?

Parent 1 Parent 2 Other (Please Specify)

1st Cabin Mate Request (must be same age/gender)

2nd Cabin Mate Request (must be same age/gender)