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Studen't Preferred Name or Tag (required)

Social Media Handle

Year Started At YACT

Student's First Name (required)

Student's Last Name (required)

Parent's Email (required)

Student's Email (required)

Student's Cell Phone (required)

Student's Gender

Student's Age (at time of Camp)*:

Student's Date of Birth: (D.O.B.)*:

Parent's Guardian #1 Name

Parent's Guardian #2 Name

Home Phone

Cell Phone




Zip Code

Emergency Contact Other Than Parent




Medical History

Current Medications


Special Dietary Needs

Student's School

Referred By A Student, Tell Us Who

Special Request

Refer A Friend. Friend's Name.

How did you hear about us? or Referred by? (required)

Comments: Enter Comments Here!

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