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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
*
Your email
Camper's First Name
*
Your answer
Camper's Last Name
*
Your answer
Camper's Age
*
Your answer
Camper's Birthdate
*
MM
/
DD
/
YYYY
Camper's Gender
*
Male
Female
Prefer not to say
Camper's Parent/Guardian's First Name
*
Your answer
Camper's Parent/Guardian's Last Name
*
Your answer
Camper's Parent/Guardian's Primary Email Address
*
Your answer
Camper's Parent/Guardian's Primary Phone Number
*
Your answer
Additional Emergency Contact - Name
*
Your answer
Emergency Contact Primary Phone Number
*
Your answer
Camper's Mailing Address - Street
*
Your answer
Camper's Mailing Address - Town/City and Zip Code
*
Your answer
Camper's County of Residence
*
Your answer
Camper's School Name
*
Your answer
Camper's School District
*
Your answer
Camper's Food or Other Allergies
*
Your answer
Camper's Current Medical Conditions
*
Your answer
Camper's Medications: Please list any medications that your child needs to take during the camp's daily schedule.
*
Your answer
Camper's Special Considerations: Please list below
*
Your answer
Camper's Pediatrician
*
Your answer
Camper's Pediatrician's Phone Number
*
Your answer
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