Application for Enrollment

When you submit this form the completed information will be emailed to the Academic Enrichment Camp.

As soon as you click submit after completing this form, the results will be displayed for you to print. You will need to print the page and mail it along with your waiver(s) and payment.

* = Required Field

Emergency Contact Emergency Contact Name * Emergency Contact Phone *

Child's Information Child's Name * Boy Girl

Date of Birth: Month Day Year *

Parent's Information Name * Daytime Phone * Alternate Phone

Address Street * City * Zip Code

2008-09 CSULB Athletic Foundation Member Yes No

CSULB Faculty/Employee Yes No If yes, what department are you in? If yes, what is your position?

Please choose a Sesson in which to enroll your child Session 1 only: 6/22 - 7/17

Also enrolled in 49er campMorning Supervision Requested($20 per family)

Session 2 only: 7/20 - 8/14

Also enrolled in 49er campMorning Supervision Requested($20 per family)

Grade Level as of Fall 2012

T-Shirt Size

Please remember to submit another separate application if enrolling for both sessions

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