JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
21st Century East Dover S.L.A.M Free Summer Camp Application
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Will your child be participating in School year program for the 2019-20 school year?
*
Yes
No
Student Name
*
Your answer
Student Phone Number
*
Your answer
Current Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
Date of Birth
*
Your answer
Bus Transportation Needed
*
Yes
No
Address for BUS pick up in AM
*
Your answer
Address for BUS pick up in PM
*
Your answer
Home Address
*
Your answer
Primary Guardian's Name
*
Your answer
Primary Guardians Contact Number
*
Your answer
Secondary Contact Name
*
Your answer
Secondary Contacts Number
*
Your answer
Does your child have any allergies
*
Yes
No
List of Allergies
*
Your answer
Medications the student is taking
Your answer
Does your child take any medications during the day while at camp? If so please fill out attached form.
*
Yes
No
Name of Physician and Physician's Phone Number
*
Your answer
Name of Dentist and Dentist Phone Number
*
Your answer
Name of Insurance
*
Your answer
Insurance Policy Number
*
Your answer
Group Number
*
Your answer
Medicaid Number
*
Your answer
Medical Conditions to be aware of:
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Capital School District.
Report Abuse
Forms
