Spring Youth Intake

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth

YYYY

Phone

(###)

###

####

School

Dietary Restrictions

Please include any dietary restrictions

Health Conditions or Allergies

Are there any health conditions or allergies you would like us to know about?

Emergency Contact

First Name

Last Name

Phone

emergency contact number

(###)

###

####

Parent Consent

I give consent for my child to participate in the youth camp

Yes