Pioneers 2022 Camper Application
What email Should we use for communications?
*
example@example.com
Camper's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Camper's Birthday
*
-
Month
-
Day
Year
Date
Campers Email
example@example.com
Campers Phone Number
Please enter a valid phone number.
What grade will the camper be entering this fall?
*
Camper's School
*
Camper's Shirt Size
*
Please Select
Youth S
Youth M
Youth L
Youth Xl
Adult S
Adult M
Adult L
Adult XL
Adult XXL
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Parent Info
Fathers Name
*
First Name
Last Name
Fathers Phone Number
*
Please enter a valid phone number.
Phone Type
*
Home
Work
Mobile
Mothers Name
*
First Name
Last Name
Mothers Phone Number
*
Please enter a valid phone number.
Phone type
*
Home
Work
Mobile
Parents' Marital Status
*
Please Select
Married
divorced
Widowed
Separated
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Additional Info
References
*
Reference Name
Reference Phone Number
Relationship To Reference
Reference One
Reference Two
Reference Three
Does your son have any activity restrictions?
*
Please Select
Yes
No
Please detail the activity restriction:
*
Does your son have any dietary restrictions?
*
None
Vegetarian
Vegan
Gluten free
Dairy free
Other
Is the camper currently taking medications or will be for the summer?
*
Please Select
Yes
No
Does your son have a recurring/chronic illness?
*
Please Select
Yes
No
Please detail the illness:
*
Has your son ever been treated for ADD or ADHD?
*
Please Select
Yes
No
Has your son Ever been treated for emotional or behavioral difficulties or an eating disorder?
*
Please Select
Yes
No
Please add more info about the emotional or behavior difficulty here:
*
Does your son have any other ongoing illness, learning disabilities or learning challenges that you have observed?
*
Please Select
Yes
No
Please detail the illness, Learning disability or learning challenge you have observed:
*
Has your son Ever Had a significant life event that continues to affect the participant's life (abuse, death of a loved one, divorce, adoption, foster care, new sibling, survived a disaster)?
*
Please Select
Yes
No
Please add more info about the life event here:
*
Is there anything you would like to add to this application?
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Pioneers Registration Fee
prev
next
( X )
Registration Fee
Credited toward tuition
$
500.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: