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Open Hearts Camp

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a-2023-Test

Camper's Name

First

Last

Camper's Preferred Nickname

First

Phone*

Address*

Street and number, P.O. box, c/o.

Address Line 2

Apartment, suite, unit, building, floor, etc.

City*

City or town

State*

State

Zipcode*

Zip Code

Age (at camp Summer 2023)*

Date of Birth*

Date of Birth

Sex*

Male

Female

Number of years at the Open Hearts Camp*

Parent(s) or Guardian(s)

Parent or Guardian*

Parent or Guardian First Name

Parent or Guardian Last Name

Phone*

Parent or Guardian 2 (if desired)

Phone 2 (if desired)

Address*

Street and number, P.O. box, c/o.

Address Line 2

Apartment, suite, unit, building, floor, etc.

City*

City

Email address*

Email address

State / Province / Region*

State

Zipcode*

Zip Code

Please indicate according to AGE the camp session in which you wish to enroll your child.*

Session One: Ages 11-12. Sunday, June 25 to Friday, July 7

Session Two: Ages 13-14. Sunday, July 9 to Friday, July 21

Session Three: Ages 15-16. Sunday, July 23 to Friday, August 4

Session Four: Ages 8, 9, 10. Sunday, August 6 to Tuesday, August 15

Cardiologist's Name

Name

First

Cardiologist's Last

Phone*

Address*

Street and number, P.O. box, c/o.

Address Line 2

Apartment, suite, unit, building, floor, etc.

City*

City

Email address

State / Province / Region*

Zipcode*

Zip Code

Please give a brief summary of child's cardiac diagnosis and present health:*

Please give a brief summary of child's cardiac diagnosis and present health:

Yes, I authorize the use of photographs/video of my child while at camp for promotional purposes only.

Yes

Please type the characters*

This helps us prevent spam, thank you.

This field should be left blank

Design

Design by Roy Bryan Web Design

Maddem Hearts Camp

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