Request Information

Parent Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone*

Email*

Request Information*

Child's Name	Gender	School	Grade (Sept. 2017)

Additional Comments or Information:

I am interested in*

Parent / Child Program (ages 18-30 months)
Junior Camp (Entering Nursery-Kindergarten)
Intermediate Camp (Entering 1st-4th Grades)
Senior Camp (Entering 5th-7th Grades)
Teen Camp (Entering 8th-9th Grades)
CIT Program (Entering 10th-11th Grades)