CiviCRM - Seatuck Environmental Association

Please complete the following registration form. If you are registering multiple people you must complete a second registration form.

Summer Camp

Child's First Name *

Child's Last Name *

Child's Birth Date *

Parent/Guardian *

Street Address *

City *

Postal Code *

Country *

State *

Phone *

Mobile *

Adult we may contact in the event of an emergency if we can't reach parent/guardian

Emergency Contact *

Person other than parent/guardian authorized to pick up child from camp

Authorized Pick-up

Email (Primary)

Event Fee(s)

Event Fee(s) *

July 1 -4 - $ 300.00

Total

Authorize.net (Credit Card)

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *