Event

Scholarship Card Number

Camper's Last Name

Camper's First Name

Camper's Email

Camper's Address

City

State

Zip Code

Camper's Date of Birth

Age

T-Shirt Size (circle one)

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Address

Health Ins. Company

Policy Holders Name

Policy #

Effective Date

Physician's Name

Physician's Phone Number

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Medical Conditions

*Please explain allergy

Release Waivers