YPDC ONLINE PRE-ENROLLMENT FORM
Last Name:
First Name:
Telephone No. Alt. Telephone No.
Email Address: Address:
Apartment #: City/Town:
State: Zip Code:

Camper #1
First Name :

Last Name:
Date of Birth : Sex:
Camper #2
First Name:

Last Name:
Date of Birth: Sex:
Camper #3
First Name: Last Name:
Date of Birth : Sex:
Weeks Your Children Will Be Attending: (Minimum 2 Week Enrollment Per Child Required)

Week Of
7/5      8/2 
7/12    8/9
7/19    8/16
7/26    8/23

Additional Information:
You May Use This Space For Additional Campers; or
To Add Any Other Information That You Would Like Us To Have.