SPACE Registration 2024

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Email *

Camp Program *

Upper SPACE (Entering 5-9)

Lower SPACE (Entering K-4)

Camper Last Name *

Camper First Name *

Grade entering 2024-25 school year *

School entering 2024-25 school year *

Camper Birthday *

YYYY

Address line 1 (street address) *

City *

State *

Zip Code *

Parent/Guardian Information

Parent/Guardian Name(s) *

Parent Phone Number *

Parent email *

Emergency Contact Information

Emergency Contact Name *

Relationship to Student *

Emergency Contact Phone Number *

I give permission to the SPACE to release photographs, videos, films, etc. in which your child appears, or to allow your child to be interviewed. This information may be used in local newspaper stories, television, and/or school department publications.
*

Yes

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