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ExRx Bootcamp Registration Form
June 18 - June 21, 2019
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Participant Email Address:
*
Your answer
Participant Phone Number:
*
Your answer
Is this a cell phone number?
*
Yes
No
Date of Birth
*
MM
/
DD
/
YYYY
Gender (used to determine housing and roommate assignment):
*
Female
Male
Transgender
Is there another camp participant with whom you would like to room? (Both participants must list each other or they may not be paired together)
Your answer
Address (permanent)
*
Your answer
City (permanent)
*
Your answer
State (permanent)
*
Your answer
Zip (permanent)
*
Your answer
T-Shirt Size
*
Your answer
There will be a luncheon on Friday, June 21st at 12:00 PM. Not including the camper, how many guests will attend?
*
Your answer
In Fall 2019, the camp participant will be attending:
*
High School
College
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