Submission Form, SummerScope

Information Request Form

Mother's Name:


First Name	Last Name

Father's Name:


First Name	Last Name

Street Address:

City:

State/Province:

Zip:

Home Phone:

Work Phone/Cell Phone:

Email:

Child's Information

Child's Name:


First Name	Last Name

Date of Birth:

Age:

Current Grade:

Previous Camp
Experience / Special Interest/Needs:

I am looking for information on:

2 week

4 week

6 week

full summer

	General Sleepaway Camp
	Teen Camps
	Outdoor Programs
	Language Learning
	Teen Tours
	Academic Programs
	Community Service
	Specialty Camps
	If Specialty, what are you looking for?

Second Child's Information