2025 Registration Form
These forms are required for your children to attend Project Pipeline
How many Students are you registering?
Please Select
1
2
3
Camper Name
*
Age
*
Gender
*
Date of Birth
*
mm/dd/yyyy
Current Grade in 2025
*
Please Select
6
7
8
School Camper Attends
*
T-Shirt Size
*
Please Select
YOUTH SMALL
YOUTH MEDIUM
YOUTH LARGE
YOUTH X-LARGE
ADULT SMALL
ADULT MEDIUM
ADULT LARGE
How did you hear about us?
Social Media
Search Engine (Google, Yahoo, ect.)
Referral
Other
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Camper's Information
Camper Name #2
Age
Gender
Date of Birth
mm/dd/yyyy
Current Grade in 2025
Please Select
K
1
2
3
4
5
6
7
8
School Camper Attends
T-Shirt Size
Please Select
YOUTH SMALL
YOUTH MEDIUM
YOUTH LARGE
YOUTH X-LARGE
ADULT SMALL
ADULT MEDIUM
ADULT LARGE
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Save
Camper's Information
Camper Name #3
Age
Gender
Date of Birth
mm/dd/yyyy
Current Grade in 2025
Please Select
K
1
2
3
4
5
6
7
8
School Camper Attends
T-Shirt Size
Please Select
YOUTH SMALL
YOUTH MEDIUM
YOUTH LARGE
YOUTH X-LARGE
ADULT SMALL
ADULT MEDIUM
ADULT LARGE
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Save
Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
example@example.com
Cell Phone
*
Home Phone
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work Name
*
Or enter N/A if not applicable
Parent's Work Phone
*
Parent's Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached while your child is at camp?
*
Cell Phone
Work Phone
Home Phone
Add second Parent/ Guardian Information?
*
Yes
No
Parents' Information
Parent/Guardian 2
Parent/Guardian 2
First Name
Last Name
Relationship to Child
E-mail
example@example.com
Cell Phone
Home Phone
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work Name
Or enter N/A if not applicable
Parent's Work Phone
Parent's Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Work Phone
Home Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Heading
Emergency Contact #1
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Relationship to Child
*
Authorized Pick Up?
*
Yes
No
Add Additional Emergency Contact?
*
Yes
No
Heading
Emergency Contact #2
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
Relationship to Child
Authorized Pick Up?
Yes
No
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Medical / Health Information
Name of Physician or Clinic/Hospital
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Is the Camper up-to-date on all immunizations?
*
Yes
No
Attach immunization record or waiver/ Email to Camp/ or Bring in person
Upload a File
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Choose a file
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Does your child have any food, medication, or environmental allergies?
*
Yes
No
Please list and explain any allergies
*
*If your child’s allergy/allergies require camp staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child, parents must submit physician authorized medical plan
0/200
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
*If special health or medical condition require camp staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during camp hours, parents must submit a physician authorized medical plan
0/200
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
*If medication, food supplement, or medical food needs to be administered at camp, parents must submit a physician authorized medical plan
0/200
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
*
*If child's dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group, parent's must submit in writing to Camp Director, and provide a physician authorized medical plan if applicable.
0/200
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
*
0/200
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions.
*
0/200
My Architecture Workshops Inc. and NOMAct has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type first and last name above to consent
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Sign Document
*
Date Signed
*
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Month
/
Day
Year
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