Jackson Hole Leadership PHASE I APPLICATION

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Email *

Child's Name *

Child's Birthday *

YYYY

Please mark your 1st Session Choice *

Session 1: June 17-21

Session 2: June 24-28

Session 3: July 8-12

Session 4: July 15-19

Session 5: July 22-26

Required

Please mark your 2nd Choice *

Session 1: June 17-21

Session 2: June 24-28

Session 3: July 8-12

Session 4: July 15-19

Session 5: July 22-26

Required

Please mark your 3rd Choice *

Session 1: June 17-21

Session 2: June 24-28

Session 3: July 8-12

Session 4: July 15-19

Session 5: July 22-26

Required

If you will be registering one or more children besides your child listed above into camp we want to make sure to timestamp their names at the same time as this initial application (this can only be for your child NOT a friend). So please input other children you will be registering here. PLEASE STILL COMPLETE A REGISTRATION FOR EACH INDIVIDUAL ADDITIONAL CHILD.

Parent(s) Name(s) *

Mailing Address *

Email *

Best Contact Phone # *

Secondary Phone # *

Please check all that apply

My child has NEVER spent a night away from home (without parents).

My child does NOT know how to swim.

Does your child have any dietary restrictions? If YES please explain. *

Does your child have any previous major surgery, illness, or other medical history that may impact their ability to participate in any activities during the week? If YES please explain. *

Does your child have any Allergies? If YES, please explain triggers/symptoms and their severity/treatment. Will they carry personal allergy medications and/or an Epi Pen?
*

Does your Child have a history of emotional, behavioral, family or school issues that you would like to discuss with a program leader prior to your session so we can best support your child's needs. *

Yes

Has your child had a significant life event that continues to affect their life (death of a loved one, family change, adoption, new sibling, survived a disaster). Please answer yes or no.

-If YES, please consider providing information about the event below, as well as care tips, so that staff can best support your child.

Is there anything else you would like staff to know about your child?

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