Youth Camp Registration Form

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University of California, Irvine – Campus Recreation
YOUTH CAMP REGISTRATION
Print Legibly
Please fill out one form per child
ENROLLMENT
Camp
Dates / Time
Fee
PERSONAL INFORMATION
__________________________________________________________________________________________________________________
Child’s Name:
First
Last
M.I.
Birth date: MM/DD/YYYY
__________________________________________________________________________________________________________________
Address:
Street
City
State
Zip
Male
Female
__________________________________________________________________________________________________________________
School
Entering Grade
T-shirt size
Age
Sex
__________________________________________________________________________________________________________________
Parent/Guardian
First
Last
__________________________________________________________________________________________________________________
Day Phone
Cell Phone
Email Address
Yes, You may use my email address to send me current and future information regarding youth programs
___________________________________________________________________________________________________________________
Local Emergency Contact:
First
Last
___________________________________________________________________________________________________________________
Day Phone
Cell Phone
Relationship
Payment Information
Amount enclosed: ___________________ Date: ___________
Cash
Check
#:______________
Credit Card: Visa
Mastercard
Credit Card#:_________________________________ Exp Date:_____________
How did you hear about us?
Email
UCI Brief
Zotmail
Returning Camper
Referred by a Friend
ARC Advertising
Campus Recreation Website
Mailed Brochure (Home)
Mailed Brochure (Work)
Inside Irvine Magazine Ad
School District Website: _________________ Other: ____________________________
FOR OFFICE USE ONLY
Fee:
Cash
Check
#
Visa
MasterCard
Verified by: ____________________
Date: ___________

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