KFL Cheer Camp at Stacey’s Studio

Cheerleader's Name (First, MI, Last):

Address:      Birth Date (MM/DD/YYYY):

City, Zip:      Age (as of July 31, 2008):     

Phone:                                                     Grade In Fall 2008: 

Parent/Legal Guardian Information

Father/Guardian's Name:  Mother's Name:
Address (if different):  Address (if different): 
Home Phone (if different):  Home Phone (if different): 
Cell Phone:  Cell Phone: 
Email:  Email: 

Do you have Personal or Group Insurance? Yes  No  (If yes, then complete the following)       

Name of Insurance Company: 

Please list all pertinent medical information, physical limitations, problems or special needs:

 

Emergency contact (other than parents):

Phone #:              Relationship: 

*Important:

In order to guarantee that your order is linked to your payment, please provide the following information:

Name on credit card used for payment