Event Registration

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HSM Summer Camp - Lost Canyon on Monday, August 5, 2019 @ 6:45 AM

*How are you connected to Mariners?:
*Date of Birth (MM/DD/YYYY)::
*Gender:
*What grade will you be Fall 2019?:
*High School Graduation Year?:
*School Student will attend in Fall 2019:
*Parent Name(s):
*Parent Email:
*Parent Cell:
Student Email:
Student Cell:
Life Group Leader (if applicable):
Student Roommate request (not guaranteed):
*Emergency contact's full name:
*Relationship of contact:
*Emergency contact's phone number:
MEDICAL CONDITIONS, ALLERGIES OR SPECIAL NEEDS (PLEASE BE SPECIFIC) Please list any medical conditions, allergies or special needs we should be aware of for the person attending this event::
NAME, DOSAGE AND FREQUENCY OF MEDICATIONS Please list any medications we should be aware of for the person attending this event. :
*Physician or Medical Clinic:
*Physician/Clinic phone:
*Name of Medical Insurance:
*Policy #:
Cabin Placement (Staff Use Only, Do not Answer):