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Summer 2015 Academy - Camp Registration Form

Personal Information
Last Name:  
First Name:  
Date of Birth:   (mm/dd/yy)
Gender:  

 
Home address:    
City:  
State:  
Zip Code:  
Preferred Phone Number:
(Please select a phone number type)
  
 
Secondary Phone Number:
(Please select a phone number type)
  
 
Email Address:  

 
Secondary Mailing Address:    
City:  
State:  
Zip Code:  
Are you Faculty, Staff, or Alumni  
Camp Adult
t-shirt size:
Please provide any medical or dietary restrictions you have (any allergies, chronic illness, or medical conditions):
 
How did you hear about this camp?

 

 Other: 

Please select the camp you are registering for:  

School Information
List your school name (middle school, junior high, or high school)
    School Name:  
    City:  
    State:  
Year in school as of Fall 2015:  
Family Information
Parent/Guardian Name  
1. Full Name  
Relationship to participant  
Phone  
Email  
2. Full Name  
Relationship to participant  
Phone  
Email  
Emergency Contact Information
1. Full Name  
Relationship to participant  
Phone  
2. Full Name  
Relationship to participant  
Phone  


 

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