Willie Hutch Jones Educational and Sports Program Steam Camp Registration

Willie Hutch Jones Educational and Sports Program Registration

Register a participant for our educational and sports programs. Please complete all relevant sections. Fields marked as required must be filled out.
Participant Information
Participant Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender*

Other
Grade camper is entering in the fall of this year:*
Parent/Guardian Information
Parent/Guardian Full Name*

First NameLast Name
Relationship to Participant*
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Participant*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Allergies (if none, enter 'None')*
Existing Medical Conditions (if none, enter 'None')*
Medications (if none, enter 'None')*
Consents and Waivers
Parent/Guardian Electronic Signature*
Should be Empty:

Willie Hutch Jones Educational and Sports Program Registration