Impact Summer Camp Form

Lewisburg Community Youth

Please fill out the form below to register your child for Impact Summer Camp 2024.

Student's First Name

Student's Last Name

Student's Birthdate

Grade for 2023-2024 School Year

Gender

T-Shirt Size (Adult Sizes)

Student's allergies or any physical, emotional, or mental limitations.

Parent/Guardian's First Name

Parent/Guardian's Last Name

Parent/Guardian's Email

Parent/Guardian's Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

I understand that:

There must be $100 in my student's account by March 24, and this payment is non-refundable.

I will receive all pertinent communication via text.

Signature