Please print out this page, fill it in, and mail it to:
Cornerstone, 16 Hickory Street, Trumbull, Ct. 06611
A $25.00 nonrefundable summer application fee must accompany this form to hold a space for your child. Please send a check or money order.

SUMMER DAY CAMP APPLICATION 2006

Today's date_____________
Child's name ____________________________________ Date of birth_______________
Address_________________________________________ Gender __________________
____________________________________________Home phone___________________

Mother or Guardian's name__________________________________________________
Employer_______________________________________ Phone____________________
Work Address_____________________________________________________________
If paying by personal check, please complete the following:
CT driver's license #_______________________________ Date of birth_____________

Father or Guardian's name__________________________________________________
Employer_______________________________________ Phone____________________
Work Address_____________________________________________________________
If paying by personal check, please complete the following:
CT driver's license #_______________________________ Date of birth_____________

Start date:_______________ Schedule: M T W R F Hours: _________to _________

A nonrefundable application fee of $25.00 and a $50.00 tuition deposit are required to hold a space for your child. The deposit can only be applied to your child's last reserved session as indicated below. The deposit is forfeited if you change your child's last session to an earlier date.

Please check your choice of sessions and dates:

Session 1 Camping Adventures ____6/26-6/30 ______7/3-7 (Center is closed Tuesday 7/4))
Session 2 Splish! Splash! ____7/10-14 ______7/7/17-21
Session 3 Rainforest Safari ______7/24-28 ______7/31-8/4
Session 4 Dinosaur Days! ______8/7-11 ______8/14-18
Session 5 Medieval Times! ______8/21-25

Our summer sessions end Friday, August 25th. If you need care until the public/parochial schools begin let us know so we may accommodate your needs!

__________________________________________________________________________

For office use only
______Application fee paid ______Deposit paid ______________Last session reserved