(Fields with * MUST be filled in!)

Applying For:
click on box(es) for desired week(s)
Session #1: June 24-28       Session #2: July 22-26        Session #3: August 5-9

Camper's Name * :

Street Address* :

City* : Zip* :

Sex* : M/F? MALE FEMALE     Age At Camp* :

Grade 2013/14* :

Home Phone* : Cell Phone*:

E-mail*:

Are you a 1st time camper? Y/N YES NO If yes, who referred you?

If you would like to be grouped with someone you are sure will be at your camp,
please enter their name.
(final decision made by Camp Director Krumpe)

Additional information or requests Coach Krumpe should be aware of:

I will include $25.00 for a new ball: Y/N? YES NO

If you are not registering siblings, go to "Complete Application Here" below...

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(1st Additional Sibling) Camper's Name :

Sex : M/F? MALE FEMALE     Age At Camp:

Grade 2013/14:

Additional information or requests Coach Krumpe should be aware of:

(2nd Additional Sibling) Camper's Name :

Sex: M/F? MALE FEMALE     Age At Camp:

Grade 2013/14:

Additional information or requests Coach Krumpe should be aware of:

(3rd Additional Sibling) Camper's Name :

Sex: M/F? MALE FEMALE     Age At Camp:

Grade 2013/14:

Additional information or requests Coach Krumpe should be aware of:

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Complete Application Here...



I hereby authorize the staff of PKSA to act for me according to their best judgment in any emergency requiring medical attention, and I hereby waive and release the camp from any and all liability for any injuries or illnesses incurred at camp. I have no knowledge of any physical impairment that would be affected by the above-named camper's participation in the PKSA camp program.
TO BE REGISTERED, YOU MUST ACCEPT ABOVE AUTHORIZATION WE ACCEPT THE ABOVE AUTHORIZATION We do not accept the above authorization and wish to withdraw our application

Parent or Guardian * :

PLEASE CAREFULLY REVIEW APPLICATION BEFORE SUBMITTING!
REMEMBER...YOU ARE NOT FULLY REGISTERED UNTIL YOU PAY!

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After submitting, an on-line payment form will automatically be forwarded to you.

Name of person submitting application*: