1. Last
Name:_____________________________________________
First:___________________ DOB _____________Age____
2. Last
Name:_____________________________________________
First:___________________ DOB_____________ Age____
Address:_______________________________________________________________________
City:________________________________
State:_________ Zip:________________________
Parent/Guardian
Name:___________________________________________________________
Relationship to the
child:______________________ Phone #:______________________________
Alternative Phone
#:______________________________ Name:___________________________
Dates of Camp
attending:____________________________________ All Day___ Half
Day______
United Sports Academy Member: Y / N Class
ID:__________________________
Do you have a referral? Y / N Name of the
referred customer/s:1._________________________
2.________________________________
3._______________________________________________
Amount Included:____________________
Payment method: Check / Cash / MC / VISA
CC#
________________-_______________-______________-_______________
Exp._____________
Cardholder
Name:____________________________________________________________________