SPEC Registration
First Name: (*)
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Middle Initial:
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Last Name: (*)
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Address:
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City:
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State:
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Zip Code: (*)
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Country
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Participant's Email: (*)
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Home Phone: (*)
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Cell Phone:
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Texting?
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Check All that Apply:
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Gender:
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Birthdate: (*)
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Last Grade Completed:
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T-Shirt Size:
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Are you a member of the following?
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Twitter Username:
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AIM Name:
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Siblings in Attendance as a Camper:
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First-time Friend Coming with Me:
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Parent/Legal Guardian:
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Home Phone:
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Work Phone:
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Cell Phone:
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Parent/Legal Guardian:
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Home Phone:
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Work Phone:
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Cell Phone:
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Parent/Legal Guardian E-mail:
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Emergency Contact:
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Home Phone:
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Work Phone:
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Cell Phone:
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Are you allergic to any foods, latex, medications, etc.?
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If Yes, Explain:
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Are you presently under a physician's care for any acute/chronic medical condition?
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If Yes, Explain:
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Are you currently taking any medications?
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If Yes, Explain:
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Do you have any physical or intellectual restrictions? Any emotional or medical conditions that need special attention?
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If Yes, please list all mental health and/or physical conditions:
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Have you recently been exposed to a contagious disease?
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If Yes, Explain:
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Any special diet needs?
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other:
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Family Physician:
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Phone:
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Attach a Copy of Your Insurance Card
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I have read and consent to the rules, guidelines and releases as specified under the Expectations of Conduct. I have read, understand and agree to abide by the Mission statement, Expectationsof Conduct, Guest Policy and Dress Code.
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