CAMP XAVIER REGISTRATION 2022

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MONDAY, JULY 25th--FRIDAY, JULY 29th

8:30am-4:30pm

Loyola High School of Los Angeles
1901 Venice Blvd
Los Angles, CA 90006

PLEASE FILL OUT THE FORM COMPLETELY. We will send you more information about Camp Xavier as soon as we receive your application. THANK YOU!!

Por favor haga clic aquí para ver este formulario en español

https://forms.gle/L8P3mSZsBsxgkqQu8

Email *

CAMPER'S FIRST NAME *

CAMPER'S LAST NAME *

CAMPER'S BIRTHDAY *

YYYY

CAMPER'S AGE *

Other:

PHONE NUMBER *

CAMPER'S SCHOOL AND GRADE (NEXT YEAR) *

Is your camper vaccinated? *

Yes

Partially

PARENT/GUARDIAN'S FIRST AND LAST NAME *

EMAIL *

ADDRESS *

EMERGENCY CONTACT NAME AND RELATIONSHIP *

EMERGENCY CONTACT PHONE NUMBER *

2ND EMERGENCY CONTACT NAME AND RELATIONSHIP

2ND EMERGENCY CONTACT PHONE NUMBER

IS YOUR CHILD ALLERGIC TO ANY TYPE OF FOOD OR MEDICATION? *

YES

Required

IF YOU ANSWERED YES, PLEASE EXPLAIN

PLEASE IDENTIFY ANY MEDICAL CONDITION OR MEDICAL HISTORY THAT WOULD REQUIRE SPECIAL ATTENTION:

PLEASE LIST ANY ACTIVITIES CAMPER SHOULD BE RESTRICTED FROM

HEALTH INSURANCE NAME *

HEALTH INSURANCE POLICY NUMBER *

This year, Camp Xavier will be offereing a coding/video game intensive, provided by Los Angeles Coding Academy, from 9am-12pm every day. If your camper is interested in learning more about this program please select YES below. *

YES

A copy of your responses will be emailed to the address you provided.

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