Bugil Wernbe Day Camp

Comments

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Student's Name(Required)

Date of Birth(Required)

Parent/Caregiver Name(Required)

Phone(Required)

Email (optional)

Dietary Requirements (if any)

Medications (if any)

Emergency Contact

Person's Name

Phone Number

Relationship

Doctors Name and Number

I consent to photos and/or media coverage during the event for promotional and/or documentary reasons.

YES

Date Form Submitted

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