Cornerstone of Hope · Lima_Kids Conquering Anxiety Camp

Participant's Information

Child/Teen Name

*

First Name

Last Name

Child/Teen Date of Birth

*

(mm/dd/yyyy)

Child/Teen Gender

Child/Teen Grade Level for 2022-2023

Second Child/Teen Name (if applicable)

First Name

Last Name

Second Child/Teen Date of Birth (if applicable)

(mm/dd/yyyy)

Second Child/Teen Gender (if applicable)

Second Child/Teen Grade Level for 2022-2023 (if applicable)

Parent/Guardian Information

Parent/Guardian Name

*

First Name

Last Name

Phone

*

Email

*

Verify Email

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Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Select Camp/Amount

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$120 - Kids Conquering Anxiety

NOTICE

Payment is required prior to beginning of camp and no other payment is required. If your child is not accepted or unable to attend for whatever reason, you will be refunded the full amount.