Premier Academy’s parents are advocates, lifelong educators and their children’s first teachers.

Summer Camp Application

SCHOOL/SITE NAME:*
Child Information
Please print name exactly as it appears on the birth certificate.*
Child's First Name Middle Child's Last Name Suffix
Last four digits of the child's social security#:*
Date of Birth (MM/DD/BY):*
MM slash DD slash YYYY
SEX:*
- Male
- Female
HOME ADDRESS (Do not enter PO Box Info):*
Street Address Address Line 2 City State ZIP Code
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1*
Parent/Guardian First Name Middle Parent/Guardian Last Name
Parent/Guardian Cell Phone:*
Parent/Guardian Email Address:*
Enter Email Confirm Email
Place of Employment:
Work Phone:
Work Address:
Street Address Address Line 2 City State ZIP Code
Parent/Guardian #2*
First Middle Last
Home Address (If different from child):*
Street Address Address Line 2 City State ZIP Code
Cell Phone:*
Email Address:*
Enter Email Confirm Email
Place of Employment:*
Work Phone:*
Work Address:
Street Address Address Line 2 City State ZIP Code
Emergency Contact Information
Persons to contact in the event that either parent/guardian cannot be contacted.
Contact #1*
First Last
RELATIONSHIP:*
CELL PHONE:*
ALTERNATE PHONE:
EMAIL:*
Enter Email Confirm Email
Contact #2
First Last
RELATIONSHIP:*
CELL PHONE:*
ALTERNATE PHONE:
EMAIL:*
Enter Email Confirm Email
Parent / Guardian Signature*
Date*
MM slash DD slash YYYY

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