Parent *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper *

First Name

Last Name

Session 1

July 7-10

Session 2

August 4 - 7

DOB *

MM

DD

YYYY

Gender *

M

F

Alternate contact *

First Name

Last Name

Alternate Phone *

(###)

###

####

Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current or past seizures?

Y

N

Does the camper currently have any communicable disease?

Y

N

Photography & Media Release

I DO

I DO NOT

Grant Mountain Life Summer Camp to take or have taken still or moving photographs or other audiovisual material and authorize Mountain Life Summer Camp to reproduce said photographs and use them for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

First Name

Last Name

Date

MM

DD

YYYY