Section 1 of 4 in this document
2020 Justin Wilcox Youth Football Camp Registration
Participant Contact Information
Participant Name
First Name
*
Initial
Last Name
*
Date Of Birth
Month
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
DD
01
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25
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30
31
Year
YYYY
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
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Full Address
Street Address
City
State
Zip
Grade in Sept. 2020
Choose One
K
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Parent/Contact
First Name
*
Last Name
*
Parent/Contact Phone Number
*
Parent/Contact Email
*
Section 2 of 4 in this document
Emergency/Medical Information
Alternate Emergency Contact (Different from Parent/Contact)
First Name
*
Last Name
*
Phone Number
*
Doctor Information
First Name
*
Last Name
*
Phone Number
Medical Insurance Company
*
Policy #
*
Policy Exp. Date
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Policy Holder Name
First Name
*
Initial
Last Name
*
Medications
Yes
No
List Medications (including inhalers)
Please list any other health information relevant to camp participation
Section 3 of 4 in this document
Participant Type
Sessions or Days
Youth Camp Session I
Monday 6/15
Tuesday 6/16
Wednesday 6/17
Thursday 6/18
Friday 6/19
Day Care 3PM - 5PM
Monday 6/15
Tuesday 6/16
Wednesday 6/17
Thursday 6/18
Friday 6/19
2020 Youth Camp
Session I
400.00
A La Carte
100.00
Aftercare
Per Day
25.00
Subtotal
Payments processed through Stripe.
Card Holder Name
Credit Card Number
Security Code
Expiration
Month
January (01)
February (02)
March (03)
April (04)
May (05)
June (06)
July (07)
August (08)
September (09)
October (10)
November (11)
December (12)
Date
Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Promo Code (CASE SENSITIVE)
disregard this