*Registration for Mini Camp Three has now closed

Choose Your Payment Option

Pay for my child to attend camp.
Pay for another child to attend camp (Gift Certificate).

Billing Information

Name as it appears on credit card


First Name
Last Name

Billing Address


Address

Address Line 2

City
Billing State

Zip Code
Country

Telephone Numbers


Home Number

Work Number

Cell Number

E-Mail Address

Credit Card Information


Type:   Visa     Master Card     American Express     Discover   


Credit Card Number
 / 
Expiration (mm/yyyy)
CVV Code

Parent / Guardian Information

Check this box if the following information and your billing information are the same.

Name


First Name
Last Name

Billing Address


Address

Address Line 2

City
Billing State

Zip Code
Country

Telephone Numbers


Home Number

Work Number

Cell Number

E-Mail Address

* needed for future correspondence for important logistical camp info

Camper Information

Camper's Name


First Name
Last Name

Camper's Gender

Camper's Age

Camper's Birthday

 /  / 

Camper's Height and Weight


Height
Weight

Camper's Grade


2010 - 2011 school year

Name Of Swim Club/Team

Others from your swim club/team attending? Check the box below:

No
Yes

T-Shirt Size

Camper's E-Mail Address

If overnight camper, I would like to room with...

Do you have a sibling who also wishes to attend camp? Click Here!
Do you have a second sibling who also wishes to attend camp? Click Here!
Do you have a third sibling who also wishes to attend camp? Click Here!
Do you have a fourth sibling who also wishes to attend camp? Click Here!
Do you have a fifth sibling who also wishes to attend camp? Click Here!

Medical Information

Emergency Contact


Contact Name

Contact Number

Camper's Physician Phone Number

Date of Last Tetanus Shot

Medication Presently Taking

Allergies

Past Illnesses Or Other Information

Insurance Carrier

Agent's Name

Agent's Phone Number

Policy Number

Any instructions regarding your insurance

Authorization

By clicking on the box to the left and entering my name and today's date into the fields below, I agree to pay the full amount for camp chosen above.

Full Name
Date