Fran Cohen Youth Center of the Salvation Army Online Registration

Registration

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Welcome to The Salvation Army Fran Cohen Youth Center. This registration is for the 2024 Summer camp only! Registration DOES NOT carry over to the school year or next summer. Please remember that Salvation Army summer camp is a full-time program.

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Referral Information

How did you hear about us?

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Do you need financial assist.?*

Special class accommodation?*

Does your child have allergies*

Hospital preference?*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone *

Work # *

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone *

Work # *

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level in 2024-25*

Transportation

Disabilities (Leave blank if NONE)*

Special Needs *

Allergies *

Medications*

Primary Doctor*

Immunizations Notes*

Grade Level in 2024-25?*

School?*

Student # and Teacher name?*

Does child know how to swim?*

Anything we should know?*

Summer camp 2024

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level in 2024-25*

Transportation

Disabilities (Leave blank if NONE)*

Special Needs *

Allergies *

Medications*

Primary Doctor*

Immunizations Notes*

Grade Level in 2024-25?*

School?*

Student # and Teacher name?*

Does child know how to swim?*

Anything we should know?*

Summer camp 2024

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level in 2024-25*

Transportation

Disabilities (Leave blank if NONE)*

Special Needs *

Allergies *

Medications*

Primary Doctor*

Immunizations Notes*

Grade Level in 2024-25?*

School?*

Student # and Teacher name?*

Does child know how to swim?*

Anything we should know?*

Summer camp 2024

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level in 2024-25*

Transportation

Disabilities (Leave blank if NONE)*

Special Needs *

Allergies *

Medications*

Primary Doctor*

Immunizations Notes*

Grade Level in 2024-25?*

School?*

Student # and Teacher name?*

Does child know how to swim?*

Anything we should know?*

Summer camp 2024

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School*

Grade Level in 2024-25*

Transportation

Disabilities (Leave blank if NONE)*

Special Needs *

Allergies *

Medications*

Primary Doctor*

Immunizations Notes*

Grade Level in 2024-25?*

School?*

Student # and Teacher name?*

Does child know how to swim?*

Anything we should know?*

Summer camp 2024

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Required Policies

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