Camp Ignite Application

Student Name*

First Last

Date of Birth*

Child's Rising Grade Level

In reading, is your child

Please pick one

Student Allergies

Student Medical Notes

Please list any medical conditions we should be aware of

Parent / Guardian #1*

First Last

Parent / Guardian #1 - Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian #1 - Phone*

Parent / Guardian #1 - Email*

Parent / Guardian #2

First Last

Parent / Guardian #2 - Address

Same as Parent / Guardian #1

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian #2 - Phone

Parent / Guardian #2 - Email

Emergency Contact*

First Last

Emergency Contact - Phone*

Emergency Contact #2

First Last

Emergency Contact #2 - Phone

Students Current School

Students Current School for 2022 - 2023 School Year

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Comments

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