Urban Sustainability Camp

Urban Sustainability Camp

Summer 2021
Participate's Information
Last Name *
First Name *
Middle Name *
Gender *

Male Female
Address *
City *
State *
Zip *
Birth Date *

Month Day Year
Grade entering in the fall *
Please select a camp week

Week 1: July 5-9 (middleschool) Week 2: July 12-16 (highschool) Week 3: July 19-23 (middleschool) Week 6: August 9-13 (highschool) Week 7: August 16-20 (middleschool)
Parent or Legal Guardian Information
Parent/Legal Guardian *
Relation *
Work Phone *

Area Code Phone Number
Cell Phone

Area Code Phone Number
Parent /Legal Guardian 2 *
Relation 2 *
Work Phone 2 *

Area Code Phone Number
Cell Phone 2

Area Code Phone Number
Home Phone *

Area Code Phone Number
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not avaliable) *
Emergency Number *

Area Code Phone Number
Emergency Number #2 *

Area Code Phone Number
Email Confirmation
Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)
Camper's Email
Health Information
Are immunications up to date?

Yes No
Date of last tetanus shot
Any activity the camper should be restricted from?
Any physical, mental or other condition that would require special attention or medication while at camp?
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.
List any allergies (ex: bees,peanuts, dairy)
Any dietary needs that we should know about?
Participate Photo Release
I agree that photos of my child can be taken on used on for camp social media purposes

Yes No
Payment Information

$415 Registration Fee
My Products
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(Paypal or Credit Card)Registration Fee+Processing Fee $ 320.00

Total $ 0.00
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. The camp carries secondary insurance. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites.
Electronic signature, please initials *

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Urban Sustainability Camp

Participate's Information

Parent or Legal Guardian Information

Emergency Contact Info

Email Confirmation

Health Information

Participate Photo Release

Payment Information