Enroll | Shine Day Camp

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Primary Parent / Legal Guardian

First Name

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Last Name

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Email Address

This email will receive important communications

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Cell Phone

Work Phone

Ext.

Street Address

0 / 100

Apt/Suite

0 / 50

City

0 / 50

Zip Code

0 / 5

Employer Name

0 / 100

Home Church or Place of Worship

All campers are welcome to participate in Shine Day camp regardless of religious affiliaton.

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Primary Parent / Legal Guardian DOB

Secondary Parent / Legal Guardian

First Name

0 / 50

Last Name

0 / 50

Email Address

0 / 100

Cell Phone

Home Phone

Work Phone

Ext.

Street Address

0 / 50

Apt/Ste #

0 / 10

City

0 / 30

State

0 / 2

Zipcode

0 / 10

Employment

0 / 100

General Account Info

Emergency Contact

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Emergency Phone

Emergency Contacts & Release of Child

List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency (Please include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released):

Emergency Contact Name

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Phone #1

Phone #2

Add Another?

Yes

No

Release of Child Only: List all individuals, other than parents/legal guardians, to whom the child may be released.

Name

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Phone #

Add Another?

Yes

No

Program Selection

Shine Day Camp

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Payment method
Amount due	USD $0.00

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