Medical Information and Release

Parent First Name

Parent Last Name*

Email*

Mobile Phone*

Camper First Name*

Camper Last Name*

Emergency Contacts

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact 2 Name*

Emergency Contact 2 Phone*

Booked Camps

Select all camps your child will be attending*

Math Made Easy (July 6-10)

Math Made Easy (July 13-17)

Math Made Easy (July 20-24)

Math Made Easy (July 27-31)

Beginner Coding (July 6-10)

Beginner Coding (July 13-17)

Beginner Coding (July 20-24)

Beginner Coding (July 27-31)

Math & Coding (July 6-10)

Math & Coding (July 13-17)

Math & Coding (July 20-24)

Math & Coding (July 27-31)

Medical Conditions and Restrictions

Please list in detail all medical conditions your child has and any required medical assistance needed during camp.*

Please describe below any allergies the your child has and the reaction seen for each.*

Restrictions*

I have reviewed the program and activities of the camp and the camper can participate without restrictions.

I have reviewed the program and activities of the camp and the camper can participate with the following restrictions described below.

Please describe any restrictions.

Acknowledgment and Agreement

I hereby give permission for any and all medical attention to be given to my child in the event of accident, injury, sickness, or other need requiring immediate medical attention. I also certify that my child is covered by medical insurance and that I will be responsible for the payment of any treatment provided. This release is effective for the dates listed in the "Booked Camps" section of this form.

Summit Math and Code Camp

Address

2024 North Randolph Street
Arlington, VA 22207

Email

dmorris@saintagnes.org

Telephone

571.289.1126

What can we help you with?

First name*

Last name*

Phone

Email*

Message

Summit Math and Code Camp

2024 North Randolph Street, Arlington, VA 22207

571.289.1126

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