CAMP GENKI SUMMER PROGRAM APPLICATION

Complete the form below and click "SUBMIT" when done. *BLUE labels indicate required fields.

Child's First Name: Child's Last Name: Parent/Guardian's First Name: Parent/Guardian's Last Name: Address: City: State: -- Select a State -- Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip Code: Primary Language Spoken At Home: Ethnicity: Phone Number: Cell Phone Number: Work Number: Email Address: Other Parent's First Name: Other Parent's Last Name: Other Parent's Address: Other Parent's City: Other Parent's State: -- Select a State -- Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Other Parent's Zip Code: Other Parent's Phone Number: Other Parent's Cell Phone Number: Other Parent's Work Number: Other Parent's Email Address: Emergency Phone Number: Child's Date of Birth: Age: Gender: Male Female Person Authorized to pick up your child: Relationship to Child: Person Authorized to pick up your child: Relationship to Child: Child's physical limitations and/or food allergies: Child's Medications: I hereby give Sweet Potato Kids, Inc. (SPK), its representatives, and approved partners permission to photograph my child and use my child's pictures in publications representing the organization.. I hereby give Sweet Potato Kids, Inc. (SPK) permission to contact me.

T-Shirt Order (enter ADULT or CHILD, size (S,M,L,XL), and Quantity):