Camp Therapyology Registration
Social Programs at a Social Distance
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
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
Fall Session #1: September 10th - October 4th
Fall Session #2: October 8th - November 1st
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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 teen/tween!
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Contact Information in Case of Emergency
Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Relation to camper
Name
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Relation to camper
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Payment
Total amount for chosen camps
Signature of applicant or guardian representative
Clear
Submit
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