DACC Summer Camp

Registration Form

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Last Name First Name MI

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Mailing Address

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City State Zip Code

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Phone E-mail

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**SS# (required) **Date of Birth (required)

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Emergency Contact Phone

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Gender Grade Entering T-Shirt Size (Adult Size)

_________________________________________ $___________

Camp Enrolling (title & date)

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Visa Mastercard

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Name on Card VIN#

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Card # Exp

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Signature Date

** If paying by check, please make checks payable to DACC Summer Camps

***It is understood that any injury sustained during the camp will be the responsibility of the parent.

Signature of Parent/Guardian:________________________________________