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: