Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

*

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 authorized person agrees to validate their identity 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

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