GLOW LEADERSHIP ACADEMY
Summer 2025
Camper's Information
Personal & Health & Contact
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
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13
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16
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25
26
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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2008
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1929
1928
1927
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1925
1924
1923
1922
1921
1920
Year
Camper Race/Ethnicity
*
Please Select
Black or African American
Hispanic or Latino
White
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Two or More Races
Age (at time of camp)
*
Please Select
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18+
Grade (entering this fall)
*
T-shirt Size:
*
Youth Small
Adult Smaill
Youth Medium
Adult Medium
Youth Large
Adult Large
Email
example@example.com
Phone Number
-
Area Code
Phone Number
List Daughter's Current School
*
List Any Allergies and Dietary Restrictions
*
Medications & Frequency
*
Parent / Guardian Information
(All correspondence and and invoices will be sent to this person)
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to the Camper
*
Emergency Contacts and Authorized Pick Up Persons
*
Program Information
Program & Payment
Select Camp Week(s)
Week 1 - June 16 - June 19 ($150)
Week 2 - June 23 - June 26 ($150)
Week 3 - June 30 - July 2 ($150)
Week 4 - July 7 - July 10 ($150)
Full GLOW Experience - All 4 Weeks ($550)
If you do not select and pay for your camp weeks now, you will receive an email and invoice to determine the preferred weeks.
One Time Registration Fee
*
$25 (Includes Camp T-shirt)
Total Cost
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Enroll My Daughter
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GLOW Leadership Academy
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