STEM Adventure Camp Registration

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About
Life House
Common Ground
- New Dawn
- Request a Tour
NextGen
- Summer Programs
Careers
Events
Donate

STEM Adventure Camp Registration

Student Information

First Name *

Last Name *

School *

Grade *

Date of Birth *

Home Address *

City *

State *

Zip Code *

Gender *MaleFemale

Guardian Information

First Name *

Last Name *

Relationship to Student *

Phone Number *

Email Address *

Home Address(if different from the student)

Emergency Contact Information

Emergency Contact 1 First Name *

Emergency Contact 1 Last Name *

Emergency Contact 1 Phone Number *

Emergency Contact 1 Relation to Student *

Emergency Contact 2 First Name *

Emergency Contact 2 Last Name *

Emergency Contact 2 Phone Number *

Emergency Contact 2 Relation to Student *

Medical Information

Does the student have any allergies? *YesNo

Please list: *

Does the student have any medical conditions we should be aware of? *YesNo

Please specify: *

Primary Physician Name *

Phone Number *

Health Insurance Provider *

Policy Number *

Consent & Agreement

Additional Students? *Please note that each student will need to be registered for the program. This field is to determine pricing and discounts.YesNo

Names of Additional Students *

Consent *

I certify that the above information is correct to the best of my knowledge.

Media Release

I have read and agree with the youth media release policy.

Address

Revive Ministries

800 South Main Street Suite C

Nicholasville, KY 40356

Email: admin@revivetomission.com

Phone: (859) 881 – 4505

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Home
About
Life House
Common Ground
New Dawn
NextGen
Careers
Events
Tours
Donate

Home
About
Life House
Common Ground
New Dawn
NextGen
Careers
Events
Tours
Donate

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