Impact Youth Mini Camp 2020
Friday, June 26th – Sunday, June 28th 2020

Application and $65 Deposit due on May 3rd, 2020
Email address *
Camper Information:
First and Last Name *
Your answer
Date of Birth *
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DD
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YYYY
Current Grade *
Your answer
Age *
Your answer
Gender *
Address (home) *
Your answer
City, State, Zip *
Your answer
E-mail *
Your answer
Home/Cell Number *
Your answer
Camper Roommate Request ( Housing will be separated girls and guys, in 2 groups: 6th- 8th Grades & 9th- 12th Grades) *
Your answer
T-Shirt Size *
Medical Information
Allergies (Medication, food, etc.): *
Your answer
Any medical, physical, or learning disabilities: *
Your answer
Medications: *
Your answer
Medical Insurance Co. Name: *
Your answer
Group: *
Your answer
Policy ID: *
Your answer
Name of Primary Ins. Holder: *
Your answer
PLEASE INCLUDE A PHOTOCOPY OF YOUR INSURANCE CARD
(Front & Back) All medication should be packed in a zip lock bag and labeled with camper’s name & instructions! Campers cannot hold ANY medication with them during camp. Our onsite nurse will hold and distribute all medications.
Parent/Guardian Information:
Parent/Guardian name: *
Your answer
Home/Cell Number *
Your answer
E-mail: *
Your answer
Emergency Contact: *
Your answer
Relationship (other than parent/guardian): *
Your answer
Home/Cell Number (of other parent/guardian) *
Your answer
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