Maplegrove Summer Camp

Welcome to the Great Start Collaborative - Wayne

Maplegrove Substance Abuse Prevention Programs Downriver
Family Questionnaire Form

[FrontPage Save Results Component]

(Parent/Guardian) First Name:
Last Name:
Relation to Child:
Street Address:
City:
State:
Zip
Email:
Phone:	- -
Marital Status:

Child's First Name:
Child's Last Name:
Age:
Birth Date:
Grade in School Fall 2009:
Does your child have special needs?
Special Education Services? If so, please describe:
With whom does the child live?

I would like to attend the parent/caregiver part of my child's camp	Yes No

Please submit a separate form for each additional child

There is no charge for this camp, but a $15 deposit per family is required to hold your place.* Please mail deposit and form to: MCPD 1 Heritage Place, Suite 230 Southgate, MI 48195

*Your place is not guaranteed until the $15 deposit is received. Deposits are returned at the end of camp. Attendance is required at 4 out of 5 sessions or your deposit is forfeited.

Make checks payable to: MCP Downriver

For more information call: (734) 285-4001, or email: MCE_CP@hfhs.org

Sponsored by: Colina Foundation, Downriver Advisory Council, Exchange Club of Trenton, 1st United Methodist Church, Maplegrove Children’s Program, Oakwood Healthcare System, Our Lady of the Angels Catholic Church, Salvation Army Wyandotte, Soroptimists International of Wyandotte, Southgate, Taylor, Soroptimists of Trenton Area, The Guidance Center, Trenton Rotary