Church Forms

Summer Youth Academy

Ages 6–16

June 22–August 14, 2009 (Monday–Friday) 7:30 am to 6:00 pm

Half of the cost must be paid on or before June 15, 2009 and the remaining balance on or before June 22. 2009.
NO CHECKS WILL BE ACCEPTED AFTER JUNE 23, 2009.

Cost: $90.00 Per Child

Required fields are marked with an asterisk (*).

Child One

Childs Name*

Age*

Last Grade Completed*

If you are only signing up one child please scroll down to Parent Information.If you are signing up more then one child please fill in the following text fields.

Child Two

Childs Name

Age

Last Grade Completed

Child Three

Childs Name

Age

Last Grade Completed

Child Four

Childs Name

Age

Last Grade Completed

Parent Information

Parent/Guardian Name*

Phone Number*

Address*

City*

Zip Code*

Work Number

Cell Number

Emergency Contact Person*

Emergency Contact Phone Nunmber*

Child Health Information

Record below any health restrictions, your child’s/children’s health card number, and any important allergies.

State you want your child/children to go swimming.
Yes | No

By submitting you agree to all of the terms on this registration form.