CAMPERS NAME

CITY

STATE

ADDRESS

ZIP

DATE OF BIRTH (MM/DD/YYYY)

AGE (at time of Camp)

GENDER

GRADE LEVELL FALL 2024

SCHOOL ATTENDING

EMAIL ADDRESS

STUDENT PHONE

ARE YOU A US CITIZEN ARE YOU A US CITIZEN YES NO

HOW DID YOU HEAR ABOUT THE STEAM CAMP

PARENT/GURDIAN NAME

ADDRESS

CITY

STATE

ZIP

PARENT HOME PHONE

PARENT WORK PHONE

PARENT CELL PHONE

PARENT EMAIL ADDRESS

Emergency Contact NAME

Emergency Contact NUMBER

ALLERGY

FOOD ALLERGY

T-SHIRT SIZE (ADULT SIZES) T-SHIRT SIZE (ADULT SIZES)SMALLMEDIUMLARGEXLXXL

As the parent/guardian, I certify that my child has permission to apply for the STEAM CAMP. My child will attend the camp and can be removed for inappropriate conduct. Students under 12 must be accompanied by an adult. As the parent/guardian, I certify that my child has permission to apply for the STEAM CAMP. My child will attend the camp and can be removed for inappropriate conduct. Students under 12 must be accompanied by an adult. I CONSENT I agree to a photo shoot

DATE (MM/DD/YYYY)