STEM Summer Camp : August 5th

STEM Summer Camp : August 5th - August 9th

SKU:

$200.00

Unavailable

per item

Camper 's Name (First, Last) *

Camper's Age *

Camper's Gender * Select at least 1 Female Male Not Specified

Camper's Address

Parent / Guardian's Name *

Parent / Guardian's Primary Phone Number *

Parent / Guardian Secondary Phone Number

Parent / Guardian E-mail *

Does the camper live with the parent / guardian? Select all that apply Yes No

Authorized To Pick Up Camper / Alternate Emergency Contact's -Name, Relation To Camper, & Phone Number

Camper's Family Physician *

Preferred Hospital

Insurance Carrier & Number (if applicable)

Known Or Suspected Allergies (Please say "none" if not applicable) *

Does Your Child Have An Epi-Pen? Select all that apply Yes No

Please list any medication your child is taking while attending camp:

Please list any recent Injuries or major illness:

Does your child have any special needs of which we should be aware of?

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