Clone of STEMVOX Summer STEM Camp Registration | Port Elgin

Health and Medical Information

Please fill in the following information carefully.
OHIP Number
Allergies (Include treatment)
Health History (Diabetes, Epilepsy, Etc.)
Additional Student*
Parent and Guardian Information

Please fill in the following information carefully.
Parent Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email*
example@example.com
Alternative Contact

First NameLast Name
Relationship to Student
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com