Variety Club Camp
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Account Type

Select Account Type:

Primary Contact for account

Enter the information for the primary contact for this account. This person must be an adult.
First Name:

Last Name:

Middle Initial:
Nickname:
Gender:
Birth Date:

mm / dd / yyyy
Address:

City:

State / Province:
*
Zip / Postal Code:

What is your child's Primary Diagnosis
*
What is your child's Secondary Diagnosis?
What is your campers t-shirt size?
*
Race & Ethnicity
*
Primary Phone
*



Alternate Phone:
*
Ext.



Alternate Phone 2:



E-mail Address:
*
Confirm E-mail Address:
*

Additional Contact for account

Add an additional contact for this account by completing the information below.
This person is:
First Name:
Last Name:
Middle Initial:
Nickname:
Gender:
Birth Date:

mm / dd / yyyy
Address:
 
City:
State / Province:
Zip / Postal Code:
What is your child's Primary Diagnosis
What is your child's Secondary Diagnosis?
What is your campers t-shirt size?
Race & Ethnicity
Primary Phone:


Alternate Phone:
Alternate Phone Ext:

Alternate Phone 2:

E-mail Address:
Confirm E-mail Address:


Login Information

The username and password must consist only of letters and/or numbers.  No special characters or spaces are allowed.
Username:
Password:
*
Confirm Password:
*
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2950 Potshop Road • Worcester • PA • 19490 • 610-584-4366
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