CIT Registration - Belleville Sportsplex

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Register as a Camp Counselor In Training

Company

Your Name *

Your Phone *

Your Cell Phone *

Your Email *

Address *

City *

State *

Zip Code *

Child Name *

Child Birthdate *

Child Gender *

Child School *

Dr. Name *

Dr. Phone *

Emergency Contact 1 Name *

Emergency Contact 1 Phone *

Emergency Contact 2 Name *

Emergency Contact 2 Phone *

Other Parent Name *

Other Parent Phone *

Any Allergies or Medications *

Pickup Name 1 *

Pickup Phone # *

Pickup Name 2 *

Pickup Name 3 *

List dates you are available *

June 1, 2020 - June 5, 2020

June 8, 2020 - June 12, 2020

June 15, 2020 - June 19, 2020

June 22, 2020 - June 26, 2020

June 29, 2020 - July 3, 2020

July 6, 2020 - July 10, 2020

July 13, 2020 - July 17, 2020

July 20, 2020 - July 24, 2020

July 27, 2020 - July 31, 2020

August 3, 2020 - August 7, 2020

August 10, 2020 - August 14, 2020

List any dates you aren't available *

Anything else we naeed to know? *

I have read and agree

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How were you referred? *

Location

Route 177
2346 Mascoutah Avenue Belleville, Illinois.

Phone: (618) 277-7111
Email: juergen@bellevillesportsplex.com

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