Empower Camp - Grade 4-7: Both 2018 Sessions Session 1 and Session 2 ALL ABOUT THE CAMPERCamper Name First Last Current Age*Birthdate*Sex* M F School Attended*Current Grade*1234567Interests (what does this camper LOVE to do?)*ALL ABOUT THE CAMPER'S PARENTS / GUARDIANSParent / Guardian 1Name* First Last Cell Home Phone*Work PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Parent Guardian 2Name First Last Cell Home PhoneWork PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email I understand that Camp EMPOWER is an active, hands-on experience for my child. Whenever there are active children, accidents can occur. I understand that Denita will be present and attentive at all times and will do her best to prevent accidents, but, yet again, there is a reason they are called accidents, I understand that they happen. Children WILL get messy (if that is something they enjoy doing) while at Camp EMPOWER. I understand that my child is to dress in appropriate clothing that they can freely explore in WITHOUT WORRY. I will not hold Denita Dinger liable for any injuries my child may attain while attending Camp EMPOWER, or stains on my child's clothing. Denita Dinger has permission to use photographs of my child for the purpose of educating others of the importance of play. Parent / Guardian Printed Name* First Last Parent / Guardian Signature Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
