Camp Registration

Summer 2022

Breakfast Around the World Registration

CAMPER INFORMATION

Camper Name

First Name

Last Name

Camper Pronouns

Camper Date of Birth

YYYY

Camper Grade (Fall 2022)

Camper Address

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1 Name

First Name

Last Name

Parent/Guardian 1 Pronouns

Parent/Guardian 1 Email

Parent/Guardian 1 Phone

(###)

###

####

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Pronouns

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

(###)

###

####

EMERGENCY CONTACT

Emergency Contact Name

First Name

Last Name

Relationship to Camper

Emergency Contact Phone

(###)

###

####

CAMPER MEDICAL

Camper Profile

Please describe any allergies, chronic illness, or medical conditions. (Write N/A if none.)

Camper Health Insurance

Group/Medical Record Number

Doctor Name

First Name

Last Name

Doctor Phone

(###)

###

####

Notes

Questions? Comments? Anything else we should know?