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Request Information About Summer Teen Programs, Tours and Trips

Please complete the form below and a TeenSource representative will call you. Please indicate the best time to call.

Note: We never share info with any third parties without your permission.
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Form completed by:	Mom Dad Child Other *
Teen will be attending summer of:	2011 2012 2013 2014 2015
How did you hear about us?	Advertisement or Direct Mail Friend Web Search Facebook Other *
Name of person who referred you:
Which CampSource consultant were you referred to?	Any consultant Abby Shapiro, Newton, MA Ellen Winer, Newton, MA Harriet Conn, Ambler, PA Sue Aaronson, Denver, CO *
Parents’ Information:
Parent 1 Full Name:	*
Parent 2 Full Name:
Address:	*
City:	*
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code:	*
Country:	*
Daytime Phone:	*
Evening Phone:
Best time and number to call:	*
Parent Email Address:	*
Teen’s Information:
Teen’s Name:	*
Date of Birth:	*
Current Age:	*
Current School Grade:	*
Name of School:
Gender:	Female Male *
Additional Siblings:
Sibling 1 Name:
Sibling 1 Birthday:
Sibling 2 Name:
Sibling 2 Birthday:
Previous summer experience:

Program Information:
Location:
USA Abroad If abroad, where?
Length of Stay:  1 Week 2 Weeks 3 Weeks 4 Weeks 5 Weeks 6 Weeks 7 Weeks Doesn't Matter
Type of Program: (check all that apply)
Academic Enrichment / Language	What discipline/language?
Arts	What type?
Community Service
Internships	What discipline?
Sports	What type?
Travel	Where?
Wilderness / Adventure

Is your teen planning to attend a summer program with a friend? If yes:
Friend's Name:
Friend's Phone Number:
Anything else about your teen that will help us fill their needs:
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