Camp 9-1-1^® 2011 Registration Form

 

Has your child attended Camp 9-1-1^® before?    Yes   □     No   □

Note: Preference will be given to those who have not attended previously.

 

Camper’s Name ________________________________________

Address  ______________________________________________

City ______________________ State _______ Zip ____________

Daytime Phone (______) _________________________________

Home Phone (______) ___________________________________

E-mail ________________________________________________

Camper’s Age ______________     Gender (circle one):     M     F

 

Special Needs or Additional Information (i.e. allergies) _________

______________________________________________________

______________________________________________________

______________________________________________________

 

Emergency Contact: Name  _________________________

Relationship ________________ Phone (______) ______________

 

Camp Locations

Using 1 and 2, choose your first and second choice of camp location:

_____ Ann Arbor        _____ Tecumseh            _____ Albion

_____ Lyon Twp         _____ Ypsilanti              _____ Plymouth  

_____ Jackson             _____ Bedford Twp       _____ Frenchtown Twp

_____ Belleville           _____ Chelsea                _____ Milan

  

______________________________________________________

Parent’s Name (please print)

______________________________________________________

Parent’s Signature

 

How did you find out about Camp 9-1-1^®? __________________

______________________________________________________

 

Complete this form and fax to Jason at 734-477-6254 or mail to:

Jason Trojan, Camp 9-1-1

Huron Valley Ambulance

1270 Goldsmith

Plymouth, MI 48170