Registration form for Grades 9-12

2025 AgHope Camp Registration Form for Grades 9-12

Please take a moment to fill out the form.

Full Name (First Name, Last Name)

Phone Number

Parent/Guardian Email

Student Email

Street Address

Birthday

School Name

School District

Medical Information

Allergies

Dietary restrictions

Current medical conditions

Medications currently taking

Health insurance information

Emergency Contact Information

Primary Emergency Contact Name

Primary Emergency Contact Phone Number

Primary Emergency Contact Email

Primary Emergency Contact Relationship

Secondary Emergency Contact Name

Secondary Emergency Contact Phone Number

Secondary Emergency Contact Email

Secondary Emergency Contact Relationship

Additional Information

Accommodation or special needs requirements.

I, the parent/guardian, have read and agree to the liability waiver.

I consent to the use of my child's image in promotional materials.

I have read and agree to the rules and behavior agreement for camp policies.

Parent/Guardian Signature

Submission Date

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