C3Kidz Day Camp
Please fill out the form completely to complete your registrations. If you have any questions, call Erin at 765-767-4009 for help. Don't forget to invite a friend!
Student Information
- The next several fields apply to the student you are enrolling.
* First Name
* Last Name
* Student's age
* Student's birth date
* Student's gender
Select one
Male
Female
* Are student's immunizations current? (Vaccinations must be up to date)
Select one
Yes, immunizations current.
No, immunizations not current.
* Name of Student's Insurance Company
* Please list current medications:
* Please list known drug and food allergies:
* Please list any additional health information you consider helpful:
* Please list any habits student may have (i.e., nail biting, thumb sucking, etc.):
Your information:
- These fields are for the name and contact info of the person submitting this form.
* Parent's First Name
* Parent's Last Name
* Email
* Mobile Phone
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