Upward Expeditions - Girls Registration Form Camper's Name(Required) Date of Birth(Required) Grade Entering(Required)7th Grade8th Grade9th GradeSchool(Required) T-shirt Size(Required)Youth-SmallYouth-MediumYouth-LargeAdult-SmallAdult-MediumAdult-LargeAdult-XLargeWill be attending(Required) Week 1 (July 31st -Aug 4) - $200 Week 2 (Aug 7- Aug 11) - $200 Both Weeks - $400 Mother's name(Required) Mother's cell #(Required)Father's name(Required) Father's cell #(Required)Parent E-mail Address(Required) Home Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact Name(Required) Emergency Contact relationship to participant(Required) Emergency Contact Number(Required)Pediatrician Name(Required) Pediatrician Phone(Required)Allergy Information Please click here to add Allergy information Allergy Information(Required)Any medication the participant will be taking during camp (i.e. Allergy, ADHD meds, advil etc)?(Required) Yes No **Please note: Upward Community will not administer medicine or oversee it.What medications is your child taking?(Required)Anything staff should know about your child (anxiety, social fears etc)(Required)Please describe your child(Required)Participant's Insurance Information:Insurance Name(Required) Group Number(Required) ID Number(Required) Name on Card(Required) Phone number of Insurance Company(Required) Consent(Required) HEALTH AND SAFETYThe Parent or Guardian certifies that the child is healthy and able to participate in all Upward Community activities at the time of application. Parent/guardian gives permission to secure proper medical treatment in case of an emergency, when parent/guardian cannot be reached. Consent(Required) WAIVER FOR PHOTO RELEASE:I give my consent for any photos/videos taken of my child involved in Upward Community programs to be used for, Upward Community and/or promotions or display. Total HiddenPayment Mode Online Offline HiddenOffline Code Credit Card(Required)Card Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.