Application Form Reading Camp
Summer 2007
Name:
Sex:
Male
Female
Age:
Parent's Names:
Daytime Phone:
Evening Phone:
Student's Birthdate:
Address:
City:
State:
State?
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
June 16 -- June 27
(one or two weeks)
I would like my child/students to begin on:
and end on:
Amount of Deposit Paid:
Arrival Times and Mode of Transportation:
Food Preferences and/or Special Needs:
Special Interests: