Winter Camp Therapyology
Social Programs at a Social Distance
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Other
Email
example@example.com
Phone Number
Mobile Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Camper T-shirt size (shirts are in adult sizes)
S
M
L
XL
Camp Session
Winter Session: December 14th - December 30th 2020
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Medical Information
Does the camper have allergies including asthma?
Please explain on the field provided
Is the camper currently under medication?
Please provide the details, the name of the medication and period of intake
Tell us a little about your "camper" (kiddo/tween/college student)!
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Contact Information in Case of Emergency
Name
First Name
Last Name
Contact Number
Relation to camper
Name
First Name
Last Name
Contact Number
Relation to camper
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Signature of applicant or guardian representative
Clear
Name
First Name
Last Name
Email
example@example.com
Phone Number
Submit
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