Camper's Name:        Parent/Guardian Name: 

Birth Date:               Gender: Male Female

Current School:        Current Grade: 

Street Address:   

Home Number:  
Daytime Phone:  
Email Address: 

Are you a foster family?: Yes: No

If yes, Foster Care Agency that referred you to JA : 

Were you referred by another organization/agency?  (ie. YWCA)  Yes No

 If yes, which one?

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