Jumpstart 2017 - Registration Form
Jumpstart 2017 will take place from July 10th to July 14th. It is a week of workshops, music instruction, and band practice, with a showcase that Friday!

Once completing this form you will be notified after application review (on a bi-weekly basis) to submit additional forms and tuition for camp.

Email address *
ABOUT THE CAMPER
Camper's First Name *
Your answer
Camper's Last Name *
Your answer
Camper's Preferred Name
If camper prefers to use a name other than their legal name, please indicate here.
Your answer
Camper's Preferred Gender Prounouns
Preferred Gender Pronouns, or PGPs, are the pronouns that an individual would like other to use when talking to, or about, that individual. Check all that apply.
Camper's Birth Date *
Please note that Rock Camp Jumpstart is for campers ages 5 - 7. For information about our program for campers aged 8 - 18, please visit http://williemaerockcamp.org/programs-page/girls-rock-camp/
MM
/
DD
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YYYY
Camper's Age at Start of Camp *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Neighborhood *
Your answer
Mailing Address
If different from previous address.
Your answer
Name of Camper's School (if applicable):
Your answer
Grade (if applicable):
Your answer
This school is (if applicable):
FAMILY/CAREGIVER INFORMATION
Name of Primary Contact *
Your answer
Email Address of Primary Contact *
Your answer
Phone Number of Primary Contact *
Your answer
Alternate Phone Number of Primary Contact
Your answer
Primary Contact's Relationship to Camper *
Your answer
Does the camper's primary contact live in the same household as the camper? *
Name of Additional Contact
Your answer
Email Address of Additional Contact
Your answer
Phone Number of Additional Contact
Your answer
Alternate Phone Number of Additional Contact
Your answer
Additional Contact's Relationship to Camper
Your answer
Does the camper's additional contact live in the same household as the camper?
Address (if different)
Your answer
Name of person filling out registration form
If not listed above.
Your answer
Relationship to Camper
Your answer
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