Primary Parent/Guardian/Educator/Mentor Name *

First Name

Last Name

Phone (We will only contact you for an emergency) *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Authorized Person for Student Drop-off/Pick-Up *

As a parent or legal guardian, I authorize my student (s) to be dropped-off or picked-up upon day of The Bill Harrison Foundation Workshop by an additional authorized person. The identified authoized person agrees to validate their identitiy on the day of camp with a valid, government issued I.D. or Passport.

Additional Authorized Person for Drop-off/Pick-up of Student *

First Name

Last Name

Additional Authorized Person Phone (We will only contact you for an emergancy) *

(###)

###

####

Student Name *

First Name

Last Name

Student Preferred Name *

First Name

Last Name

Student Allergies/Dietary Restrictions *

Student has no known allergies/dietary restrictions

Peanuts

Shellfish/Seafood

Soy

Milk and Dairy Products

Egg

Wheat Nuts

Gluten

Vegetarian

Vegan

Other

Student is capable of using scissors without parent/guardian supervision during program's model building *

Yes

No

Does the student hae any access requirement or limitations due to learning disability or physical, emotional, behavioral difficulties you would like the Workshop Directors to be aware of? *

Yes

No

Other

Primary Parent/Guardian/Educator/Mentor Name *

First Name

Last Name

Please confirm that the student is available for all workshop sessions of Blueprints to Build, except in cases of circumstances beyond their control.

Yes, Student is available for all 7 sessions

No, Student is not available for all 7 sessions