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Respite Weekend Interest Form
Completion of this form DOES NOT register your camper for Respite Weekends. This form is the first step in the process; Kat Witt, the Support Specialist, will be in contact for next steps.
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* Indicates required question
Camper Name (Last, First)
*
Your answer
Camper Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Address - Number, Street
*
Your answer
Address - City, State, Zip
*
Your answer
Parent 1/Guardian 1 Name
*
Your answer
Parent 1/Guardian 1 Email Address
*
Your answer
Parent 1/Guardian 1 Phone Number
*
Your answer
Parent 2/Guardian 2 Name
Your answer
Parent 2/Guardian 2 Email Address
Your answer
Parent 2/Guardian 2 Phone Number
Your answer
Is Parent/Guardian address the same as Camper address? (If No, please check "Other" and write in Parent/Guardian address)
*
Yes
Other:
Which Respite Weekends is the camper interested in attending? (Check all that apply)
*
October 4-6
January 10-12
March 27-29
Not sure yet
Required
How did you hear about Respite Weekends?
Website
Friend
Teacher/School
Another camp
Other:
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This form was created inside of Camp Wood YMCA.
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