Personal Information
Applicant's Name *
Applicant's Name
Birthdate *
Birthdate
Gender *
Mailing Address *
Mailing Address
Health Information
Applicant's Name *
Applicant's Name
Doctor's Phone *
Doctor's Phone
Parent/Guardian *
Parent/Guardian
Parent/Guardian Address *
Parent/Guardian Address
Parent/Guardian Cell Phone *
Parent/Guardian Cell Phone
Parent/Guardian Home Phone
Parent/Guardian Home Phone
Parent/Guardian Work Phone
Parent/Guardian Work Phone
Emergency Contact *
Emergency Contact
This should be someone different than the person named as your Parent/Guardian.
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
Emergency Contact Home Phone
Emergency Contact Home Phone
Emergency Contact Work Phone
Emergency Contact Work Phone
Health History
Are you subject to any of the following? *
Have you been treated by a health care professional for any medical/emotional conditions in the past 12 months? *
Are you on a special diet? *
If you do not have any allergies, please write 'none'.
If you are not taking any medication, please write 'none'.
I declare this health history to be accurate to my knowledge. I hereby give permission to the doctor/nurse selected by the camp to provide me with medical treatment in the case of an emergeny.
Signature *
Signature
Parent/guardian if applicant is under 18 years of age.
Date *
Date
Program Costs
The cost of the program is $100 for the week. Please indicate how you will be paying.
Payment Options *