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