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

T-Shirt Size *

Youth S

Youth M

Youth L

Adult S

Adult M

Adult L

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 9-13, 2025

June 16-20, 2025

June 23-27, 2025

July 7-11, 2025

July 14-18, 2025

July 21-25, 2025

Does your child have any allergies and/or dietary restrictions? *

Yes

No

Does your child have any medical conditions or special needs? *

Yes

No

Is your child currently taking any medications? *

Yes

No

Camper's Primary Care Physician *

First Name

Last Name

Phone

(###)

###

####

Emergency Medical Authorization *

I authorize Iron Village Preparatory Academy staff to seek emergency medical treatment for my child if necessary.

Photo/Video Release *

I grant permission for my child to be photographed/video recorded for promotional materials and social media.

I do not grant permission.

Behavioral Expectations Agreement *

I understand that Iron Village Preparatory Academy maintains a safe, inclusive environment and that my child must adhere to behavioral guidelines.

Liability Waiver *

I release Iron Village Preparatory Academy from any liability related to injuries or accidents during camp activities.

Date

MM

DD

YYYY