New Customer Registration Form

Welcome aboard Cteen Extreme Summer Camp 5784 - 2024!

Please fill out the following form accurately and completely. This information will help us ensure a safe and enjoyable trip for all participants.

Trip Details:

- Destination: Mumbai-Goa

- Mumbai Dates: May 12th to May 14th

- Goa Dates: May 15th to May 19th
Teen's Personal Information:
Name*

First NameMiddle NameLast Name
Teen's Date of Birth*

DayMonthYear
Date
Current Age*
Nationality*
Teen's E-mail
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Teen's Phone Number*
What standard will you be entering in June? (or just entered)*
Parent Contact number*
Please enter a valid phone number.
Parent/Guardian's Name*
T-shirt Size*

Extra SmallSmallMediumLargeExtra LargeXX LargeXXX LargeOther
Emergency Contact Information:
Emergency Contact Name:*
Relationship to Teen:*
Contact Number:*
Please enter a valid phone number.
Email*
example@example.com
Medical Information:
Allergies (if any):
Current Medications (if any):
Chronic Illnesses/Conditions (if any):
Dietary Restrictions:
Any Recent Injuries/Surgeries:
Blood Type (if known):
Health Declaration:
Signature (Teen):*

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Signature (Parent/Guardian):*

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My Products

Registration fee

2,200.00INR

Enter coupon

Total

0.00INR

Should be Empty: