Whitworth Home Page > Summer Programs >

Camp Registration Form

How many children would you like to register? (required)

Register two or more children (either friends or siblings is fine) at the same time to receive a $25 discount per registration.

Student #1 Information

Grade Level (2016-17) (required)  

First Name (required)

Last Name (required)

Preferred First Name (required)

E-mail Address (required)

Phone (10 digit number) (required)

Address Line 1 (required)

Address Line 2

City, State (required)

ZIP/Postal Code (required)

Birthday (required)
 /   / 

Gender (required)

School (required)

T-Shirt Size (required)

Ethnic Origin

Special Needs (if any)

List your preferred classes below and we will do everything possible to make sure you are in two of these three.

Class Preference #1

Class Preference #2

Class Preference #3

Class Preference #4

Child’s Insurance Company (required)

Name of Insured Parent (required)

Insurance Group Number (required)

Family Physician

Family Physician's Phone Number

Parents/Guardian Information

Number of Parents/Guardians (required)
1 Parent/Guardian Name

Parent/Guardian E-mail Address

Parent/Guardian Phone

Parent/Guardian Employer/Occupation

Parent/Guardian Address

Is your child currently enrolled in a Highly Capable Program (gifted and talented education)?

Parental Consent


Parent's Name (required)  

Payment Information

Payment (required)  

Your total registration cost: $250