Summer Camp Application
(please type or clearly print all information & feel free
to duplicate this form)

Name_________________________________
Age_______ Male_____ Female____
Parent/Guardian_________________________
Address_______________________________
City, State, Zip__________________________
Phone (work)_________ (home)___________
Phone (cell)___________ e-mail______________

If you DO NOT wish parent/guardian name to be added to our Accessible Arts mailing list please check here __

List special needs related to visual impairment, mobility, developmental, mental or other disabilities (see note on previous page).
____________________________________________
____________________________________________

Week #1, July 24-28, 2006
_____ (# of children) x $250 = _________

Week #2, July 31-August 4, 2006
______ (# of children) x $250 = ________
TOTAL ENCLOSED________
___Enclosed is my letter requesting a scholarship
(no scholarships will be given after July 17th)

Please send this form and your check payable to
Accessible Arts, Inc., 1100 State Ave., Kansas City, KS 66102
Phone: 913/281-1133 ~ Fax: 913/281-1515