Summer Manufacturing Inclusion Camp Application
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
*
Format: (000) 000-0000.
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
*
Format: (000) 000-0000.
Back
Next
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
Back
Next
Contacts Information in Case of Emergency
In addition to Parent/Guardian already listed.
Name
*
First Name
Last Name
Contact Number
*
-
Area Code
Phone Number
Relation to Camper
*
Name
*
First Name
Last Name
Contact Number
*
-
Area Code
Phone Number
Relation to Camper
*
Back
Next
Agreement
Camper Signature
*
Parent/Guardian Signature
*
Submit
Should be Empty: