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2012 YOUTHQUAKE REGISTRATION

FEBRUARY 17-19, 2012 - AGES 12-17

An additional late fee of $15.00 will be assessed for all
applications received after the close of our office (5pm)
on the Tuesday before camp.

APPLICATIONS CAN NOT BE PROCESSED IF INCOMPLETE

APPLICATION AND REQUIRED MEDICAL FORM

Camper Full 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: