Tara Wildlife Summer Camp Registration & Enrollment Form How Can We Reach You?Name of Person Filling Out Form(Required) First Last Your Email(Required) Enter Email Confirm Email Can We Send You Email about Your Camp Registration?(Required) Yes No About The CamperCamper's Name(Required) First Middle initial Last Camper's Gender(Required)Select an optionMaleFemaleBirth Date(Required) Age(Required)What School Do You Attend?(Required)Home Address Street Address Address Line 2 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 Medical Notes ~ Special Instructions ~ Dietary Needs or Concerns ~ Food Allergies: Please note Mississippi Department of Health requires all medications to arrive in original packaging.Camper's Family InformationHow did you hear about Tara Camps?(Required)Select onePosterFriend, Neighbor, or Relative (word of mouth)Social MediaWeb SearchPreviously AttendedWho Does the Camper Live With?(Required)Select One OptionBoth ParentsMotherFatherOtherFather's Name(Required) First Last Home Phone(Required)Cell PhoneMother's Name(Required) First Last Home Phone(Required)Cell PhoneGuardian's Name(Required) First Last Home Phone(Required)Cell PhoneAlternate responsible person (not parent) to be reached in case of emergency if parent or guardian is unavailable:Name(Required) First Last PhoneRelationship to CamperPlease list below any special considerations or persons who are never to be authorized to pick up your child.Camp SelectionsWhich Camp Are You Registering For?(Required)Select the campCamp III (June 21 – 27) (19 items remaining)Camp IV (July 12 – 18) (0 items remaining)Camp V (July 19 – 25) (28 items remaining)Junior Camp (June 7 – 12) (29 items remaining)Advanced/Archery (June 14 – 19) (33 items remaining)Roommate RequestPrevious Years Attended CampPaymentPayment Options(Required)Select how you want to payPay Deposit Only ($400)Pay in Full ($800)Payment MethodPayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Total
