Name of Camper *

First Name

Last Name

Camper Date of Birth *

MM

DD

YYYY

Session Preference *

Please check one NOTE: Sessions listed below are dates and locations which still have availability for camper enrollment.

Little Winners Camp (May 27-3 at Pembroke Hill School High School)

Session 1 (June 2 -5 at Pembroke Hill School High School)

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone *

(###)

###

####

Are you a participant in any of the following programs? Check all that apply.

Free or Reduced Lunch Program

Aid to Families with Dependent Children (AFDC)

Supplemental Security Income (SSI)

Supplemental Security Disability Insurance (SSDI)

Women, Infants & Children (WIC)

Subsidized Housing (HUD)

Food Stamps

Unemployment Benefits

Supplemental Nutrition Assistance Program (SNAP)