6PDC GLAM Camp 2024 Registration August 5th-16th (Mon-Fri) 9:00am-4:00pm Name* First Last Age Birthdate* MM slash DD slash YYYY Today’s Date* MM slash DD slash YYYY Parent/ Guardian Name* Address* Street Address City State 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 Zipcode Day Phone:*Evening Phone:Email*Used to send you a receipt and important updates Emergency ContactFill out this section if emergency contact is different from above.Name* First Last Phone*Relationship to child* Authorized Pick Up List*Please describe any learning or physical disabilities your child may have. Leave section blank if the latter doesn’t apply.ENROLLMENTPlease check the Week Session(s) your child will be attending:* Entire Session: August 5th-16th (Mon-Fri) 9:00am-4:00pm Week 1: August 5th- August 9th (Mon-Fri) 9:00am-4:00pm Week 2: August 12th -16th (Mon-Fri) 9:00am-4:00pm *Extended Care available 7:30am-6pm Registration FeeHiddenWaiver I have read and agree to the Waiver and Release. Registration Total $0.00 PAYMENT METHODSelect Your Payment Method*PayPal CheckoutCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name
