CY Summer Camp 2017 - Deposit/Form
 
CY Summer Camp 2017 - Deposit/Form
Attendee Age  * 
Attendee Last Name  * 
Attendee First Name  * 
Attendee Birthdate  * 
Attendee Gender  * 
Attendee Address  * 
Attendee Phone  * 
Attendee Email  * 
Attendee Grade  * 
Emergency Contact Name  * 
Emergency Contact Relationship  * 
Emergency Contact Cell Phone  * 
Does the attendee have any diseases/physical limitations or any kind?  * 
Is the attendee restricted from any activities?  * 
Does the attendee have any allergies (Food, Medical, Insect, etc.)?  * 
Does the attendee have an EpiPen?  * 
Family Physician
Family Physician Phone
Does the attendee take prescription medication?  * 
Medication 1
Medication 1 Purpose
Medication 1 Dosage, Frequency Taken, Time of Day Taken
Medication 2
Medication 2 Purpose
Medication 2 Dosage, Frequency Taken, Time of Day Taken
Medication 3
Medication 3 Purpose
Medication 3 Dosage, Frequency Taken, Time of Day Taken
I (adult parent/guardian) have received a copy of the "Youth America Summer Camp Information and Medical Release Form" to complete on behalf of my student.  * 
Pay Deposit - $50 (Due 4/28/17) or Pay Full Amount - $250 (Due 5/26/17) $ 
Your Email Address  * 
Total $
 
 
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