Camper Name

Birthdate

Gender

Email Address

Parents Names

Street Address

City

Zip

Preferred Phone

Alternate Phone

Emergency Contact &
Pick-Up Authorization Name

Phone

School

Grade in Fall 2012

Allergies

Emotional, behavioral or learning disabilities

How did you hear about GreenPlay?

I have read and agreed to the Camp Policies.

I have read and agreed to the Waiver and Release.