Youth Summer Camp Registration Form

Youth Summer Camp Registration Form
Classes are priced at $275 and can be paid ONLINE BY CLICKING HERE
Camper Information
Campers Name

First NameLast Name
Preferred Name/Nickname
Optional
Camper's Date of Birth

MonthDayYear
Age
Gender

Parent/ Guardian Information
Parent/Guardian 1 Name

First NameLast Name
Relationship to Camper
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Name (Optional)

First NameLast Name
Relationship to Camper
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact and Medical Information
Emergency Contact (Other Than Parents)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any Known Allergies? If So, Please List Them Below.
Any Known Medical Conditions or Special Needs? If So, Please List Them Below.
Current Medications
Physician Name
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Provider
Policy Number
Immunizations Up To Date?

Permissions
Photo/Video Release
In Case Of Emergency, Medical Treatment Authorization
Liability Waiver Agreement
Behavior Agreement Consent

Optional Information
Friend Request (Grouping Preference)
Camper's Hobbies and Interests
How Did You Hear About Us?

Other
Classes are priced at $275 and can be paid ONLINE BY CLICKING HERE
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