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Child's Name
As of June 1st
Mobile/Home
Please complete all the information requested, if not applicable mark N/A
Parent/Guardian Name
Mobile/Home
Town/City State Zip Code
Employer and Occupation
Parent/Guardian Name
Town/City State Zip Code
Employer and Occupation
2 emergency contacts are required
Emergency Contact
Mobile/Home
Town/City State Zip Code
Emergency Contact
Mobile/Home
Town/City State Zip Code
Please provide the names of people in addition to parents/guardians who are permitted to pick up your child below
Name
Name
Name
Please complete required fields below. Mark N/A if necessary
Please list any medical problems, including any requiring maintenance and or medication (i.e. Diabetic, Asthma, Seizures)
i.e. Inhalers, specific medication
Do you consent for the paramedics to be called to treat your child in case of emergency?
Please list any special dietary needs.
How did you heard about the A Place wit Nia Youth Program /Summer Explorer Camp.
Additional shirts can be purchased for $10.00
Please read terms and photo release info to the end and initial
Printed Signature of Parent/Guardian*
*My printed name here is acting in place of a signed signature
mm/dd/yyyy
Price: $50.00
The $50.00 registration fee includes 1 T-shirt.
Price: $50.00

Camp Schedule: Mon -Fri 9am-4pm

Make Checks Payable to: A Place wit Nia Youth Program (include Childs name on memo)

aplacewitnia@gmail.com

Los Angeles, Ca 90018