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1. ABOUT THE CAMPER

First Name:
Last Name:
Date of Birth:
Age (at time of camp)
School camper attends:

How did you hear about Girls Rock Philly?

Does the camper have any medical conditions or allergies? Yes No

If yes, please list:
Is the camper on any medication to treat these conditions? Yes No

If yes, please list:
Does the camper have any behavioral or emotional issues? Yes No

If yes, please list:
Is the camper on any medication to treat these conditions? Yes No

If yes, please list:
T-Shirt Size: Youth: XSM SM MED LG
Adult: SM MED LG XL XXL
OPTIONAL: What ethnicity do you consider yourself?: Chicana/Latina
White/European American
Middle Eastern/Arab American
Black or African-American
Asian or Pacific Islander
Native American
Other