ART CAMP REGISTRATION

At KARDIA UMC, 1637 Butler Ave. LA, CA 90025

August 11-15. 9am - 12noon

Suggested Donation $300 (covers all materials and supplies)

ages 4+

Child's Name

First Name

Last Name

Child's Age

Child's Birthdate

MM

DD

YYYY

Grade

Please indicate child's grade level and school.

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Home Phone

Note: Please only use numbers for this entry. No other characters allowed.

Parent Name

First Name

Last Name

Cell Phone

Note: Please only use numbers for this entry. No other characters allowed.

Parent Name

First Name

Last Name

Cell Phone

(###)

###

####

Other Emergency Contact

First Name

Last Name

Emergency Contact's Phone Number

Note: Please only use numbers for this entry. No other characters allowed.

Doctor's Name

First Name

Last Name

Doctor's Phone Number

Note: Please only use numbers for this entry. No other characters allowed.

Allergies

Please list any allergies your child may have.

Further information will be provided upon registration. Please email Joey Hargrove (joeydh@aol.com) with any questions.

Art Camp Registration (Copy)

ART CAMP REGISTRATION