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Kirkwood Science Camp Registration Form
You must fill this form out for each child that is participating in the camp as a camper or a CIT.
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* Indicates required question
Email
*
Your email
Parent Name
*
Your answer
Parent Phone number
*
Your answer
Parent email address
*
Your answer
Home Address (Street, City, State, Zip)
*
Your answer
Participant Name
*
Your answer
Child Age (at time of camp)
*
Your answer
Camp Shirt Size
*
Kids S
Kids M
Kids L
Adult S
Adult M
Adult L
Women S
Women M
Women L
Camp Sessions Registered (check all that apply)
*
Session 1
Session 2
Session 3
Session 4
Required
Alternative Emergency Contact (name and phone number)
*
Your answer
Health Insurance Company and Policy Number
*
Your answer
Please tell us about any medical history or present conditions that may affect participation in a group hike or outdoor learning environment.
*
Your answer
List any medications the participant is taking.
*
Your answer
List the participant’s allergies.
*
Your answer
Use the space below to tell us any other pertinent information about the participant.
*
Your answer
Waiver
I/WE HAVE CAREFULLY READ THIS AGREEMENT; I/WE UNDERSTAND IT INCLUDES A FULL RELEASE OF LIABILITY EXCEPT AS EXPRESSLY STATED ABOVE; AND I/WE AGREE TO ITS TERMS. I/WE ARE OVER 18
*
Yes
No
PARENT/LEGAL GUARDIAN SIGNATURE- THE PARENT MUST TYPE THEIR FULL NAME TO AGREE
*
Your answer
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