Last Name __________________________________________________________

Camper Name _____________________________________________ Sex _______

Camper's E-Mail Address ________________________________________________

Address ____________________________________________________________

City _________________________________________________ ZIP ___________

Telephone ______________________________________ Birthdate _____________

School ______________________________________________ Current Grade ______



Mother _______________________________________ Work Phone _____________

Cell ______________________________ Pager _____________________________

E-Mail Address ________________________________________________________



Father ________________________________________ Work Phone _____________

Cell ______________________________ Pager _____________________________

E-Mail Address ________________________________________________________


Please check how often you might use Extended Care:

_ regularly _ occasionally _ not at all

How early in the morning would you like E.C. available?

__________________________________

Until what time would you like E.C. available in the afternoon?

__________________________________

Please list all weeks for which you are registering at this time:

__________________________________

__________________________________

__________________________________

A non-refundable deposit of $50
is required for each week.

Enclosed is check number __________ made out to
Youth Services from Mars for $ __________.
I understand that the balance payment
is required by June 1st.

__________________________________________________ signature

________________ date

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