Girls Camp Registration 2019
Boston & Blackstone Valley Stakes 2019 Girls Camp Registration July 22 - 27, 2019
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Home address, city, state, zip code *
Your answer
Camper Mobile Number *
Your answer
Camper Email *
Your answer
Stake *
Ward *
T-shirt size *
Swimmer Ability *
Level for 2019 *
Parent/Guardian Name *
Adult Leaders - list spouse or emergency contact name
Your answer
Parent/Guardian Cell Phone number *
Adult Leaders - list spouse or emergency contact cell phone number
Your answer
Parent/Guardian Work number
Adult Leaders - list spouse or emergency contact work number
Your answer
Other Parent/Guardian Name
Your answer
Other Parent/Guardian Phone number
Your answer
Other Parent/Guardian Work number
Your answer
If parent/guardian above is not available in an emergency, notify person listed below:
Adult Leaders - list alternate emergency contact
Your answer
Alternate Emergency Contact Relationship
Your answer
Alternate Emergency Contact Phone Number
Your answer
Name of Personal Physician *
Your answer
Physician phone *
Your answer
Personal Health Insurance *
Your answer
Policy Number *
Your answer
List dietary restrictions
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Mark which ones apply: *
Required
If you checked off on any of the above (other than None), please explain below:
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