Winter Camp Detailed Registration Form

United Winter Camp Registration
Student Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number*
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number*
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Special Diet: Please check any that apply*

non celiac Gluten Freeegg freeDairy freeNut freeveganvegetariandiabeticNo rescrictions
Medical Insurance Policy and Policy Number*

Camp Registration

(Pay Now) 6th-12th Grade Registration

$180.00

Pay Later

$ Free

Total

$0.00

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

United Winter Camp Registration