Please enroll my child. I understand that the Diamond Star Camps or anyone associated with the camps will not accept any responsibility for accidents or injuries incurred at the Clinic.

CHILD'S NAME: ___________________________________________________________
MAILING ADDRESS:_______________________________________________________
EMAIL ADDRESS: _________________________________________________________
DATE OF BIRTH: ______________________________ CURRENT AGE: ____________
HOME TELEPHONE: _______________________________________________________
CHILD'S MEDICAL INSURANCE PLAN: ______________________________________

My child is in good health and has my permission to participate.

______________________________________
Parent/Guardian Signature

_________________
Date

Home Phone #: 536-3139
E-mail:tusqueze@roadrunner.com
Web site: www.diamondstarcamps.com