Individual Application

To apply for Encounter 2010, please complete the following form. You will then be presented with a printable PDF to be signed by your parents/guardians and a medical form to be signed by your doctor.

* Fields marked with an asterisk are required.

 

 

Parents / Guardians & Emergency Contacts

Parent / Guardian One

Name *
Address *
City *
Zip *
State *		-- Select -- Alabama Alaska Arizona Arkansas California California Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone (am) *
Phone (pm) *
Cell
Email Address *

Parent / Guardian Two

Name
Address
City
Zip
State		-- Select -- Alabama Alaska Arizona Arkansas California California Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Phone (am)
Phone (pm)
Cell
Email

Additional Emergency Contact

Name *
Phone (am) *
Phone (pm) *
Cell
Relationship *

Insurance & Medical Information

Insurance Coverage

I am covered by hospitalization and medical insurance I do not have medical coverage and assume responsibility for the cost

Medication (dosage & frequency), allergies, illnesses, etc.		If participant is on medication of any kind (even over the counter medication), information must be indicated below and medication must be with participant for the week without exception! If none, please write "none" in the box above.
Medication		I do not want my child to be given any medication
Dietary Restrictions		If none, please write "none" in the box above.