Camp Destination Innovation Registration Form
Email address *
Participant's Name *
Your answer
Participant's Birth Date *
Your answer
Participant's Home Address *
Your answer
Participant's School Name *
Your answer
Participant's Grade Level (IE: Freshman, Junior, etc) *
Your answer
Participant's T-Shirt Size *
Participant's Gender
Participant's Age
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Participant lives with:
Your answer
Participant's Race/Ethnicity
Your answer
Participant's Insurance Policy Number
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Participant's Health Insurance Provider
Your answer
Participant's Primary Physician
Your answer
Participant's Hospital Preference(s)
Your answer
Medical Condition(s) that the Camp Destination Innovation staff needs to be aware of. Please also list any medication the Participant needs to take.
Your answer
Is the Camp Participant currently being treated for any injuries or illnesses? If so please list what they are.
Your answer
Is the Camp Participant allergic to any type of food or medication or require a special diet? If so please list what they are.
Your answer
Parent/Guardian's Name(s) *
Your answer
Parent/Guardian's Phone Number(s)
Your answer
Parent/Guardian's Email(s)
Your answer
Parent/Guardian's Home Address (if different from above)
Your answer
Parent/Guardian's Occupation(s)
Your answer
Parent/Guardian's Employer(s)
Your answer
Parent/Guardian's Income(s)
Emergency Contact's Name *
Your answer
Emergency Contact's Phone Number *
Your answer
Emergency Contact's Email *
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Emergency Contact's Relation to Participant *
Your answer
Please list any people in addition to the Parent(s) / Guardian(s) / Emergency Contact who are permitted to pick up the Camp Participant (if applicable)
Your answer
Is there any other information that you believe would be valuable for the Camp Destination Innovation staff to know?
Your answer
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