Camper Registration

Child's Information

Date of Birth

HAS child previously attended Camp Smile?

Yes No

DOES child have a visual impairment?

Yes No

DOES child have any other special needs?

Yes No

If you have any comments on your child (e.g. particular areas of interest, behavior patterns) that would help make "Camp Smile" more enjoyable, please indicate them below.

Desired Sessions

Week 1

Week 2

Week 3

Week 4

Parents/Guardians

Provide information of at least one parent/guardian.

Emergency Contacts

You must provide a back-up Emergency Contact unless there are multiple parents / guardians listed in the previous section.

Bus Pick-Up

Does your child require bus transportation to and from camp?

Yes, child WILL require bus transportation.

Email this Parent/Guardian updates and communications from Camp Smile

Mother's Day Roses