8/18/2019 2016 Youth and Teen Registration Form
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MECKLENBURG COUNTY PARK AND RECREATION DEPARTMENT
Therapeutic Recreation
REGISTRATION FOR SUMMER DAY CAMP !"#
YOUT$ AND TEEN SUMMER DAY CAMPMUST COMPLETE ONE %"& FORM PER CAMPER ' (( PLEASE PRINT ((
CAMPER'S NAME: _______________________________________________________________________________
AGE: _______________ DOB: ____/____/____ SEX: M F
T-SHIRT: Youth Small Youth M!"um Youth #a$% A!ult Small A!ult M!"um
A!ult #a$% A!ult X# A!ult &X# A!ult X#(O) T-*h"$t +$ +a$t","+a)t "* "),lu!! ") Summ$ Da Cam+ $%"*t$at"o).
ADDITIONA# T-SHIRT FEE: )"*+!! per ,hirt Ch, "0 ou a$ +u$,ha*")% a) a!!"t"o)al T-*h"$t
DISABI#ITY:
PARENT/G1ARDIAN NAME:
ADDRESS:
CITY: STATE: 2IP:
HOME PHONE: 3OR4 PHONE: CE## PHONE:
EMAI#:
3 Ch, 3*
Dat* (5 6 7 a$* ol!.Litt-e Bi. Ca/p
To/ S01e, RC8:9 am 6 :9 +m
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MLK RC8:9 am 6 :9 +m
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MLK RC8:9 am 6 :9 +m
(;5 6 &; a$* ol!.TREC
Marion Dieh- RC8:9 am 6 :9 +m
; 5/; 6 5/;8
8/18/2019 2016 Youth and Teen Registration Form
2/2
ADA State/ent
Th M,l)@u$% Cou)t Pa$ a)! R,$at"o) D+a$tm)t "ll ,om+l "th th Am$",a)* "th D"*a@"l"t"* A,t (ADA.h",h +$oh"@"t* !"*,$"m")at"o) o) th @a*"* o0 !"*a@"l"t= M,l)@u$% Cou)t "ll ma $a*o)a@l a,,ommo!at"o)* ")all +$o%$am* to )a@l +a$t","+at"o) @ a) ")!""!ual "th a !"*a@"l"t ho mt* **)t"al l"%"@"l"t $u"$m)t*=M,l)@u$% Cou)t +$o%$am* "ll @ aa"la@l ") th mo*t ")t%$at! *tt")% 0o$ a,h ")!""!ual= I0 a)
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Inc-u,ion State/ent
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I al*o a%$ o) @hal0 o0 m*l0 a)! th +a$t","+a)t )ot to ma a) ,la"m* o$ !ma)!* o0 a) ")! a%a")*tM,l)@u$% Cou)t o$ a) o0 "t* m+lo* o$ a%)t* 0o$ a) lo** o$ ")u$ that th +a$t","+a)t m"%ht *u*ta") h"l)%a%! ") th TR Summ$ Da Cam+ +$o%$am "),lu!")% t$a)*+o$tat"o) to th +$o%$am *"t=
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A 0ull $0u)! "ll @ "**u! 0o$ +$o%$am* ,a),ll! !u to lo )$ollm)t o$ "),lm)t ath$= A +a$t"al $0u)! ($0u)!m")u* a ;9J *$", ,ha$%. "ll @ "**u! h) th $%"*t$a)t *u@m"t* a $"tt) $u*t 0o$ a $0u)! a m")"mum o0 t)(;9. !a* @0o$ th +$o%$am *ta$t !at= A +a$t"al $0u)! (m")u* a ;9J *$", ,ha$%. "ll al*o @ a++$o! "0 th$%"*t$a)t *u@m"t* a +h*","a)* ltt$ a!"*")% a%a")*t +a$t","+at"o) @0o$ th 0"$*t ***"o)=
NO REFUND "ll @ a++$o! l** tha) t) (;9 !a*. @0o$ th 0"$*t !a o0 a,h o0 ,am+ ("thout a +h*","a)*ltt$.=
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R,"! @: Sta00: _________________________________________ Dat: _____________
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