Student Applicant Information
Space is still available for Iberia Parish camp. Calcasieu and Lafayette camps are currently full! You will be placed on a waiting list. Please Complete all questions below:
Student Applicant Name
*
First Name
Last Name
Student Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Student Applicant Gender
*
Please Select
Male
Female
Prefer not to answer
Name of School Currently Attending
*
Current School Grade Level
*
Please Select
5th
6th
7th
8th
Name of school entering in fall of academic year 2023-24
*
What grade will student applicant be entering in the 2023-2024 academic year?
*
Please Select
6th
7th
8th
9th
Student Applicant Ethnicity/Race
*
African American/Black
American Indian
Asian
Caucasian/White
Hispanic
Pacific Islander
Other
What parish does the student applicant currently reside? Space is still available for Iberia Parish camp. Calcasieu and Lafayette camps are currently closed, you will be placed on a waiting list.
*
Transportation for this program is not available. Do you have reliable transportation to and from the camp site each day?
*
Yes
No
Student Applicant T-Shirt Size
*
Please Select
Small
Medium
Large
X-Large
XX-Large
XXX-Large
Student Applicant Career of Interest
*
Please list up to 3 careers that student is potentially interested in.
Student Applicant Phone Number
*
Please enter a valid phone number.
Parent Phone Number
*
Please enter a valid phone number.
Student Applicant Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Contact Information
Parent/Legal Guardian Name and Relationship
*
Full Name
Relationship to Student Applicant
Parent/Legal Guardian Phone Number
*
Please enter a valid phone number.
Parent/Legal Guardian Email
*
Parent/Legal Guardian Name and Relationship
Full Name
Relationship to Student Applicant
Parent/Legal Guardian Phone Number
Please enter a valid phone number.
Parent/Legal Guardian Email
Emergency Contact Information
Emergency Contact Name and Relationship
*
Full Name
Relationship to Student Applicant
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Name and Relationship
Full Name
Relationship to Student Applicant
Emergency Contact Phone Number
Please enter a valid phone number.
Student Applicant Health Information
Please list all medical conditions, if any, for the Student Applicant
*
If none, please put N/A
Please list all allergies, if any, for the Student Applicant
*
If none, please put N/A
Physician Name
*
First Name
Last Name
Physician Phone Number
*
Please enter a valid phone number.
Please upload a copy of the FRONT of the student applicant health insurance card.
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Please upload a copy of the BACK of the student applicant health insurance card.
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Please upload your current report card.
*
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