2019 Girls' Leadership Summer Camp
9 a.m. - 3 p.m.
Monday - Friday, June 10-14, 2019
APSU Honors Commons
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Email *
First Name of Student *
Last Name of Student *
Student Date of Birth *
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Student age at time of camp *
Student Grade in School (August 2019) *
Name Student Prefers (if other than given name)
Name of School (August 2019) *
Student T-shirt size (women's) *
Full Name of Parent or Legal Guardian *
Parent/Guardian Street Address *
Parent/Guardian City *
Parent/Guardian State *
Parent/Guardian Zip Code *
Parent/Guardian Home Phone *
Parent/Guardian Mobile Phone *
Parent/Guardian Work Phone *
E-mail address parent/guardian checks frequently *
Best way to contact parent/guardian *
Emergency Contact Name *
Emergency Contact Relationship to Child *
Emergency Contact Phone Number *
Additional Emergency Contact Name *
Additional Emergency Contact Relationship to Child *
Additional Emergency Contact Phone Number *
Does your camper have any medical conditions, allergies, or special needs the staff should know about? If so, please describe. *
Does your camper have any behavioral or emotional issues the staff should know about? If so, please describe. *
Is your camper taking any medications to treat these conditions?  If so, please list. *
Health Insurance Company Name *
Health Insurance Policy Number *
Health Insurance Subscriber Name *
Subscriber Relationship to Camper *
In addition to the parent/legal guardian listed above, the individual(s) listed below may pick up and sign out my child.  A valid photo ID is required at each pick-up and sign-out.   *
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