Mercer Creative Computer Camp Registration Form - 2020
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Camper Information
Camper's first name? *
Camper's last name? *
Camper's current age? *
Camper's birth date? *
mm/dd/yyy
Camper is a: *
Select a T-Shirt size: *
Which camp for the week of June 1-5, 2020? *
Which camp for the week of June 8-12, 2020? *
Which camp for the week of June 15-19, 2020? *
Do you want to also enroll in the After Camp Program?  ($35 additional charge)
Please enroll my child in the After Camp Program for the weeks checked below.  This enables my child to stay at camp until 5:15pm.  I will pay the extra $35 for each week.
Parent/Guardian Information
Parent's first name? *
Parent's last name? *
Parent's email address? *
Parent's primary contact phone number? *
Parent's alternative phone number?
Parent's street address?
Parent's City, State, Zip?
Medical Information
Enter as much information as you can.  You will be able to add more information later.
Medical Insurance Company for Camper?
Insurance Policy Number?
Insurance Group Number?
Person to contact in an emergency (after Parent/Guardian)?
Emergency contact's relationship with Camper?
Emergency contact's phone number?
Camper's Physician's Name
Camper's Physician's phone number
Physical Limitations (Asthma, diabetes, allergies, etc.) and/or Special Instructions (Allergic to certain meds, rare blood type, wears contact lenses, etc):
List ALL medication taken on a regular basis and/or any brought with you to camp. (Prescription meds MUST have a pharmacy label and name of doctor.)
List all operations/serious injuries and dates within the past (5) years:
Other Information
Promotion Code?
How did you hear about Mercer's Creative Computer Camps?
Any additional comments?
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