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Northbrook Summer Camp Registration 2020
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Child's Last Name
Your answer
Child's First Name
Your answer
Parent/Guardian Name
Your answer
Street Address, City, State, Zip
Your answer
Phone Number
Your answer
Email
Your answer
If one parent does not live with the youth or child please fill out the following information if we are to contact that parent also.
Parent/Guardian Name
Your answer
Street Address, City, State, Zip
Your answer
Phone Number
Your answer
Email
Your answer
Child's birthday
MM
/
DD
/
YYYY
Grade for the 2021-2022 School Year
Your answer
Special medical concerns, allergies, current prescriptions (including instructions for taking any prescriptions if given during Camp):
Your answer
Is this child covered by medical insurance?
Yes
No
Other:
Clear selection
Carrier's Name
Your answer
Carrier's Address (leave blank if same as above)
Your answer
Relationship to Child
Your answer
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