2019 Application

Fill in form and pick the age appropriate Session

Camper's Name(required)

Camper's Preferred Nickname

Address(required)

Age (at camp Summer 2017)(required)

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, Sunday, June 23, 2019 to Friday, July 5, 2019

Session Two, 13-14, Sunday, July 7, 2019 to Friday, July 19, 2019

Session Three, 15-16, Sunday, July 21, 2019 to Friday, August 2, 2019

Session Four, 8, 9, 10, Sunday, August 4, 2019 to Tuesday, August 13, 2019

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)

This field should be left blank

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