VBCamp 2008 Agent-In-Training Application

Child's Name:

Birth Date:
Year: 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 Month: January February March April May June July August September October November December Date: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Child’s Age Group: (Class your child is entering Fall 08):4 years (by Sept. 1, 2008) 5 years (by Sept. 1, 2008) Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade

Parent/Guardian's Name:

Home Phone: ( ) -

Mailing Address:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:

Email Address:

Emergency Contact's Name (other than parent):
Relationship to child::
Phone Number: ) -

Food/Medication Allergies:

Does this child have any special needs (physical, emotional, or developmental)?
Yes No
If so, explain:

Holy Cross has my permission to use photos and/or video of my child through the website, church screens and written media. A "yes" indicates your approval,"no" indicates we may not use them. Yes No