Camper Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Race *

Black or African American

Asian

White

American Indian/Alaskan Native

Native Hawaiian or Other Pacific Islander

Mixed Race

Gender (Optional)

Male

Female

Camper's Expected 2024-25 Grade Level *

1st

2nd

3rd

4th

5th

6th

7th

8th

Camper's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Phone Number *

(###)

###

####

Additional Phone (Optional)

(###)

###

####

Which week(s) are your registering your camper to attend? *

(Select all that apply. Campers receive a 10% discount for multi-week registration.)

June 10-14, 2024

June 17-21, 2024

June 24-28, 2024

Camper's T-Shirt Size *

(Youth Sizes)

YXS

YS

YM

YL

YXL

My child wears adult sizes.

Camper's Primary Care Physician *

First Name

Last Name

Phone

(###)

###

####

By checking this box, I authorize Iron Village Preparatory Academy to use photos of my child for marketing purposes.