Child's Name *

First Name

Last Name

What Weeks Will Your Child Attend

All Weeks

Week 1 June 2nd - June 6th

Week 2 June 9th - June 13th

Week 3 June 16th - June 20th

Week 4 June 23rd - June 27th

Week 5 June 30th - July 4th

Week 6 July 7th - July 11th

Week 7 July 14th - July 18th

Week 8 July 21st - July 25th

Week 9 July 28th - August 1st

Are you applying for a scholarship? *

Yes

No

Behavior Support Needed? *

Yes

No

Guardian Information *

First Name

Last Name

Phone *

(###)

###

####

Guardian Information

First Name

Last Name

Phone

(###)

###

####