Summer Camp Registration – Lake Wylie Lutheran Preschool

Child's Name *

Child's Birthdate *

Month *

Day *

Year *

Parent/Guardian's Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Home Phone Number

Daytime Phone Number *

Emergency Contact Name

Emergency Contact Phone Number

Names of individuals authorized to pick up your child:

Allergies:

Any medical conditions we should be aware of:

Child's Physician

Physician's Phone Number

2025 Summer Camp Registration Form