Camp Registration

First Name *

Last Name *

Gender
Male Female

Date of Birth *

Address *

Country * Select Country United States

State * Select States Alabama Alaska Arizona Arkansas Byram California Cokato Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Lowa Maine Maryland Massachusetts Medfield Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Jersy New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Ramey Rhode Island South Carolina South Dakota Sublimity Tennessee Texas Trimble Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

City * Select City Apex Asheboro Asheville Boone Burlington Carrboro Cary Chapel Hill Charlotte Clayton Clemmons Concord Cornelius Durham Fayetteville Fuquay-Varina Garner Gastonia Goldsboro Greensboro Greenville Havelock Hickory High Point Holly Springs Huntersville Indian Trail Jacksonville Kannapolis Kernersville Kinston Lexington Lumberton Matthews Mint Hill Monroe Mooresville Morrisville New Bern Raleigh Rocky Mount Salisbury Sanford Shelby Statesville Thomasville Wake Forest Wilmington Wilson Winston-Salem

Zip Code

Preference to Group with any kid * We try our best to meet your request

About Student

Doctor's Name*

Doctor's Phone No.*

Has Allergies or Medical Condition?
Yes No

About Allergies or Medical Condition *

Has Dietary Restrictions?
Yes No

Dietary Restrictions *

School*

Grade*

Track * Select Tracks Track 1 Track 2 Track 3 Track 4 Traditional Modified

Does your child have an IEP?
Yes No

Please provide details below :*

Insurance Name

Card Holder

Employer

Policy No.

Group No.