REGISTRATION

Campers Name	Gender
Birth Date
School	Grade Fall 2008
Home Address	Phone
City	State Zip
Parent/Guardian’s Name
Home Address (if different)
City	State Zip
Parent/Guardian’s Email Address
Parent’s/Guardian’s Daytime Phone Number
Eve Phone Number	Mobile Number
Name emergency contact if parent guardian in unavailable
Relationship to camper
Phone number(s) of emergency contact
Medical Insurance Carrier	Policy Number
List any medical conditions and or medications required. Please include all medications with prescription/dosage, physician name and phone number.
Any other pertinent information that you want the camp to know about your son or daughter?

SUMMER SCIENCE CAMP
August 3-8, 2008

U N LO C K T H E M Y S T E R I E S O F S C I E N C E

800-DR-PLANK
P.O. Box 492 Malibu, CA 90265
drplank@plankinstitute.com