SJHS Summer Camp

Choose Camp(s)

Student Name*

First Last

Grade Entering*

as of September 2022

Elementary School*

Student Address*

Street Address Address Line 2 City State ZIP Code

Parent Name

First Last

Parent Email*

Parent Phone*

Youth Shirt Sizes

Adult Shirt Sizes

MEDICAL RELEASE AND PERSONAL LIKENESS WAIVER

Signature of Parent/Guardian*

Name of Physician*

Physician's Phone Number*

Health Insurance Carrier*

Agreement/Policy Number*

Please list any medical conditions.