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Camp Registration Form
Please fill out the information below for your Sickle Cell Warrior to attend Camp Sickle Stars.
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* Indicates required question
Email
*
Your email
Camper Name:
*
Your answer
Camper Date of Birth:
*
MM
/
DD
/
YYYY
Grade:
*
Your answer
Sex
*
Male
Female
Parent/Guardian Name:
*
Your answer
Parent/Guardian Valid Cell Phone Number
*
Your answer
Parent/Guardian Work Phone Number (if none, enter N/A)
*
Your answer
Parent/Guardian Email:
*
Your answer
Physical Address:
*
Your answer
Insurance Company
*
Your answer
Insurance Number
*
Your answer
Medicaid Number
*
Your answer
Primary Physician Name
*
Your answer
Primary Physician Number
*
Your answer
Primary Physician Address
*
Your answer
Is there anything specific that you would like for us to know about your Warrior. (If nothing, enter N/A.)
*
Your answer
Camper T-Shirt Size
*
S
M
L
XL
Other:
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