I Would Like to Apply to: *

July

August

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date-of-Birth *

MM

DD

YYYY

Grade *

10th

11th

12th

Sweatshirt Size *

XS

S

M

L

XL

2XL

Father's Name *

First Name

Last Name

Father's Cell # *

(###)

###

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Father's Work #

(###)

###

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Mother's Name *

First Name

Last Name

Mother's Cell # *

(###)

###

####

Mother's Work #

(###)

###

####

Home Phone # *

(###)

###

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Emergency Contact

First Name

Last Name

Emergency Contact #

(###)

###

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School Reference #1 *

First Name

Last Name

Phone # ( School Reference 1) *

Please ensure to provide a direct contact number and not the school's contact number.

(###)

###

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School Reference #2 *

First Name

Last Name

Phone # (School Reference 2) *

Please ensure to provide a direct contact number and not the school's contact number.

(###)

###

####

Camp Reference #1 *

First Name

Last Name

Phone # (Camp Reference 1) *

Please ensure to provide a direct contact number and not the camp's contact number.

(###)

###

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Camp Reference #2

First Name

Last Name

Phone # (Camp Reference 2)

(###)

###

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Are you applying with any friends? *

Yes

No

How did you hear about Camp Nesiot *

Friend

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Other

Any special dietary needs? *

Gluten Free

Dairy Free

Other

Not Applicable