Leadership Camp Registration Form
Camper's Information
Camper Name
*
Date Of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Camper Phone Number
-
Area Code
Phone Number
Entering Grade in 2021/22
*
Please Select
9th
10th
11th
12th
Other
T-Shirt Size
*
Please Select
Small
Medium
Large
X-Large
XX-Large
Camp Registering For
*
Please Select
> July 24
> July 31
> August 07
.
>> July 24 & 31
>> July 24 & Aug 07
>> July 31 & Aug 07
.
>>> July 24 & 31 & Aug. 07
The name of you campers High School and District
*
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Medical / Health Information
Does your camper have any allergies?
*
Yes
No
Please explain
*
0/150
Does your camper have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Does your child have any dietary restrictions?
*
Yes
No
Please explain
*
0/150
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Format: (000) 000-0000.
Home Phone
*
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Phone
Format: (000) 000-0000.
Parent Information
Parent/Guardian 2
Parent/Guardian 2
First Name
Last Name
Relationship to Child
E-mail
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Home Address Same as Parent/Guardian 1?
Yes
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Work/School Phone
Format: (000) 000-0000.
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Emergency Contacts/Authorized Pickup
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
*
Format: (000) 000-0000.
Secondary Phone Number
*
Format: (000) 000-0000.
Relationship to Child
*
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
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child
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Camp Fees
$20.00 Per Session
I Wish To Pay My Camp Fees:
*
Pay By Cash Day Of Camp
My Students School Is Sponsoring Payment & I Will Turn In A Copy Of The Payment Agreement
Please Upload A Copy Of The Payment Agreement.
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Registration Notes
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SUBMIT
Should be Empty: