EmailMe Form - 2019 Camp Safety Package

Child's Information

Student's Name *

First Last

Nickname

Gender *

Male

Female

Date of Birth *

MM / DD / YY

Age of Entry *

First Day of Attendance

MM / DD / YY

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Family Information

Person listed as PRIMARY Parent/Guardian will be the sole person authorized to request changes to information and/or cancellation of services.

Primary Parent/Guardian’s: *

Mother

Father

Other

Full Name *

First Last

Email *

Mobile Phone *

### - ### - ####

Mobile Phone Provider *

Same address as child's? *

Yes

No

Address: (if different to child’s) *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Add Secondary Parent/Guardian? *

Yes

No

Crossing Borders cannot legally deny access to or release of a child to either parent/guardian, unless there is an active restraining or court order on file.

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