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2010 WYR REGISTRATION

FEBRUARY 19-21, 2020 - AGES 12-17

APPLICATION AND REQUIRED MEDICAL FORM

Camper Name:
Male
Female:
Birthdate:
Age:
Mailing Address:
City:
State:
Zip:
Home Phone:
E-mail (confirmation page
will be sent here):
Method of Payment: Already Paid Online
Will Send Payment By Mail
   
PARENT/GUARDIAN INFO  
Parent/Guardian Name:
Home Phone:
Cell Phone:
Work Phone:
   
EMERGENCY CONTACT INFO  
Emergency Contact Name:
Emer. Contact Home Phone:
Emer. Contact Cell Phone:
Relationship to Camper:
Person(s) Picking Up Camper on Sunday:
   
MEDICAL INSURANCE CARRIER  
Medical Insurance Carrier:
Group No.:
Insurance Policy No.:
Allergies(drugs/other):
List any Medications camper
is currently taking: