2022 Application

Session One, 11-12 year olds, June 26 to July 8

Session Two, 13-14 year olds, July 10 to July 22

Session Three, 15-16 year olds, July 24 to August 5

Session Four, 8, 9, 10 year olds, August 7 to August 16

Camper's Name(required)

Camper's Preferred Nickname

Address(required)

Age (at camp Summer 2022)(required)

8

9

10

11

12

13

14

15

16

Date of Birth(required)

Sex(required)

Female

Male

Number of years at the Open Hearts Camp(required)

Name of Parent(s) or Guardian(S)(required)

Phone Numbers(required)

Email address(required)

Address(required)

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

Session One, 11-12 year olds, June 26 to July 8

Session Two, 13-14 year olds, July 10 to July 22

Session Three, 15-16 year olds, July 24 to August 5

Session Four, 8, 9, 10 year olds, August 7 to August 16

Cardiologist Name(required)

Address

Email address

Phone Number(s)(required)

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

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

yes

Type the characters(required)

Send

This field should be left blank