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Summer 2014 Academy - Camp Registration Form

Personal Information
Your Full Name:  
     Last  
     First  
Date of Birth:   (mm/dd/yy)
Gender:  
Home Address:  
    Number/Street  
   
   
    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  
    Number/Street  
   
   
    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 2014  
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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