Pre-Registration Form

Parent Information

Name(s)*

Address:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Phone:*

Area Code

Phone Number

E-mail:

Name:*

First

Last

Gender:

Male

Female

Other

Prefer not to say

Birthdate:

day

month

year

Grade:

Please describe or explain briefly.

Attention Issues:*

Social Issues:*

Compliance Issues:*

Self-Regulation Issues:*

History of Summer Camp Experience:

How did you find out about Camp Attaway?

Follow the directions to confirm you are a real person: