2011 Camp Brown Registration

BASIC INFORMATION (about the camper)

* First Name

* Last Name

* Date of Birth

* Age

* Sex

Male

Female

* Grade (Fall 2011)

* School child attended 2010-2011

* Street Address

Apartment/Unit #

* City

* State

* Zip Code

* Please attach a recent photo of the camper.

* Washington, D.C. Resident?

Yes

Please attach or fax proof of Washington, D.C. residency to the Registrar at 202.397.1301.

Acceptable documents include: current utility bill (mobile phones are not accepted), pay stub, valid driver's license or current lease agreement.

Metropolitan Police Department (MPD) District

* Please select sessions below:

Session 1 (Mind, Body & Soul!) FULL (MAXIMUM ENROLLMENT REACHED)

Session 2 (Showtime): July 4 to July 8

Session 3 (Olympics): July 11 to July 15

Session 4 (Homecoming): July 18 to July 22

Session 5 (Go Green): July 25 to July 29

Session 6 (International): August 1 to August 5

Session 7 (Adventures): August 8 to August 12

* Please select sessions below:

Session 1 (Mind, Body &Soul!) FULL (MAXIMUM ENROLLMENT REACHED)

Session 2 (Showtime): July 4 to July 8

Session 3 (Olympics): July 11 to July 15

Session 4 (Homecoming): July 18 to July 22

Session 5 (Go Green): July 25 to July 29

Session 6 (International): August 1 to August 5

Session 7 (Adventures): August 8 to August 12

CONTACT INFORMATION

* Parent/Guardian First Name

* Parent/Guardian Last Name

* Street Address

Apartment/Unit #

* City

* State

* Zip Code

* Phone Number

* Cell/Alternate Phone Number

* Email Address

EMERGENCY CONTACT INFORMATION

In case of emergency (if parents cannot be reached), please provide TWO contacts other than parents. (Must be 18 or older)

Emergency Contact 1

* First Name

* Last Name

* Relationship

* Phone Number

* Cell/Alternate Phone Number

Emergency Contact 2

* First Name

* Last Name

* Relationship

* Phone Number

* Cell/Alternate Phone Number

RELEASE AUTHORIZATION

Please list any person authorized to pick up your child other than parent/guardian.
Please include first name, last name and phone number.
Authorized persons must be 18+.

* Indicates Response Required