Willie Hutch Jones Educational and Sports Program Steam Camp Registration

Participant Information
Willie Hutch Jones Educational and Sports Program Registration

STEAM Camp is currently full. You are welcome to complete this application to join our official waiting list. If a space becomes available, families will be contacted in the order they are selected from the waiting list.
Steam Camp Waiting list
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