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Participant Application
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
How old will you be at the start of camp? (June 30th)
*
Choose
11
12
13
14
15
16
17
18
19
20
21
22
Have you been to camp before?
*
Yes
No
Street Address
*
Your answer
City
*
Your answer
State
*
Choose
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WV
WI
WY
Zip Code
*
Your answer
Parent Phone Number
*
Your answer
Parent Email Address
*
Your answer
Personal Phone Number
Your answer
Email Address
Your answer
Gender
*
Male
Female
T-Shirt Size
*
Choose
X Small
Small
Medium
Large
XLarge
XXLarge
Education
School Name
*
Your answer
Current Grade
*
Your answer
Health
If not applicable to you (i.e. no allergies, medicine, or medical history), write N/A
Do you have any special dietary restrictions?
*
Yes, I am a vegetarian
Yes, I am a vegan
Yes, I am lactose-intolerant
No
Other:
Allergies (include severity) or Medications
*
Your answer
Medical or Illness History
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Relationship
*
Choose
Mother
Father
Sibling (above 18)
Friend (above 18)
Relative
Other
Emergency Contact Phone Number
*
Your answer
Medical Insurance
*
Your answer
Policy Number
*
Your answer
What do you hope to gain from this workshop? Any worries or concerns?
*
Your answer
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