Student's Full Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Please mark the week(s) your child will be attending *

Please select any week that your student will attend, even if not for the full week.

July 3-7

July 10-14

July 17-21

July 24-28

July 31- August 4

August 7-11

August 14-18

Will your student be attending full weeks or individual days?

A representative of Chapel Field will reach out to set your student's schedule if necessary.

Full Weeks

Individual Days

Guardian #1 Name *

First Name

Last Name

Cell Phone Number *

(###)

###

####

Work Phone Number

(###)

###

####

Home Phone Number

(###)

###

####

Preferred Contact Number *

Cell Phone

Work Phone

Home Phone

Guardian #2 Name

First Name

Last Name

Cell Phone Number

(###)

###

####

Work Phone Number

(###)

###

####

Home Phone Number

(###)

###

####

Preferred Contact Number

Cell Phone

Work Phone

Home Phone

Emergency Contact #1 *

First Name

Last Name

Contact Number *

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Contact Number *

(###)

###

####