Summer Manufacturing Inclusion Camp Application
Hosted at World Wide Technology in Edwardsville. Brought to you by BCI.
Camper Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Camper Email
*
example@example.com
Camper Mobile Phone Number
*
Camper Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Camper School
*
Grade Camper Will Enter This Fall
*
9th
10th
11th
12th
Camper's Diagnosed Disability
*
Camper's Known Support Needs/Accommodations
*
Camper T-Shirt Size (shirts are in adult unisex sizes)
*
Small
Medium
Large
Extra Large
XXL
XXXL
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Mobile Phone
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Medical Information
Does the camper have allergies including asthma?
*
Please explain on the field provided
Is the camper currently taking medication?
*
Please provide the details, the name of the medication and period of intake
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Contacts Information in Case of Emergency
In addition to Parent/Guardian already listed.
Emergency Name 1
*
First Name
Last Name
Emergency 1 Phone Number
*
-
Area Code
Phone Number
Relation to Camper
*
Emergency Name 2
*
First Name
Last Name
Emergency 1 Phone Number
*
-
Area Code
Phone Number
Relation to Camper
*
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Agreement
Camper Signature
*
Parent/Guardian Signature
*
Submit
Should be Empty: