CAMP INVENTION REGISTRATION INFO

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CAMP INVENTION REGISTRATION INFO:
The Independence School
1300 Paper Mill Rd
Newark, DE 19711
June 27 - July 1, 2016 from 9:00AM to 3:00PM
Directed by Tanya Godsey
[email protected]
Price $350 (Before discount)
For children entering 1st - 6th grade
Registration price is $350
Please fill out completely and return to: Tanya Godsey, The Independence School
PROGRAM INFORMATION
Program Location: The Independence School
When: June 27 – July 1, 2016 From 9:00AM to 3:00PM
PARENT/PARTICIPANT INFORMATION
Parent/Guardian Name(s)
Street Address
City
Home Phone
State
Cell/Alternative Phone
Email
Child’s Name
Male 
Child’s Date of Birth
Does your child require an EpiPen®?
Female 
 Yes  No
Special Needs
School Child Attends
PAYMENT INFORMATION
Method of Payment:
Signature
Check #
Please make checks payable to The Independece School
Date
Fall Grade Level
Zip