Camp 911

Student Name *

Student Grade
(this coming fall) *

Student's School *

T-Shirt Size * Select ... Youth XS (2-4) Youth S (6-8) Youth M (10-12) Youth L (14-16) Youth XL (18-20)

Student Allergies or Medical Conditions *

Parent or Guardian Name *

Parent or Guardian Phone

Name of
Emergency Contact *

Emergency Contact
Phone Number *

Do you grant permission to Morris Hospital and Camp 911 to use any photographs, recordings or any other record of this event for any legitimate purpose consistent with HIPAA and its related Rules and Regulations and other state laws?*

Photo Consent * Select ... Yes No

By submitting this electronic signature, you as parent or guardian grant permission for this student to participate in Camp 911.

Electronic Signature *

Billing Name *

Billing Email *

Please note: You will receive a confirmation email once you complete online registration. If you do not receive this email, your child is not registered for this event. You may call 815-705-7358 for further information.

Billing Address *

Billing City/Town *

Billing State

Billing Zip Code

Billing Phone *

I consent to my submitted data being collected and stored as outlined by the site .