Registration TIU 11 Summer Camp 2022
Please complete a separate form for each child.

Please contact Stephanie Daniels with any questions at sdaniels@tiu11.org or 814-542-2501 x115
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Email *
Camper's First Name *
Camper's Last Name *
Camper's Age *
Camper's Birthdate *
MM
/
DD
/
YYYY
Camper's Gender *
Camper's Parent/Guardian's First Name *
Camper's Parent/Guardian's Last Name *
Camper's Parent/Guardian's Primary Email Address *
Camper's Parent/Guardian's Primary Phone Number *
Additional Emergency Contact - Name *
Emergency Contact Primary Phone Number *
Camper's Mailing Address - Street *
Camper's Mailing Address - Town/City and Zip Code *
Camper's County of Residence *
Camper's School Name *
Camper's School District *
Camper's Food or Other Allergies *
Camper's Current Medical Conditions *
Camper's Medications: Please list any medications that your child needs to take during the camp's daily schedule. *
Camper's Special Considerations: Please list below *
Camper's Pediatrician *
Camper's Pediatrician's Phone Number *
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