Bustin Barriers Camp Registration Form
Summer 2017. This form take about 10-15 minutes to complete. There is a consent form at the end for you to print and sign.
Campers Last Name *
Your answer
Campers First Name *
Your answer
Campers Middle Initial *
Your answer
Year in School *
School Attending *
Your answer
Date Of Birth *
MM
/
DD
/
YYYY
Race *
Your answer
Gender *
Parent / Legal Guardian *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email *
Your answer
Daytime Phone Number *
Your answer
Evening Phone Number *
Your answer
Emergency Contact - Name of responsible neighbor or relative and contact number (if parent cannot be contacted): *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship *
Your answer
Camper's Doctor (Name) *
Your answer
Doctor Phone Phone Number *
Your answer
Preferred Hospital *
Your answer
Does the camper have a favorite sports activity or play a team sport? If yes, please list sport/activities: *
Your answer
Camp Selection *
Required
Camp Fee and Method of Payment
Camp costs $150/week. (Scholarships opportunities are available - please contact us for information.)
Payment Method *
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