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Student Information
Student Name
*
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*
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Add a 2nd Parent/Guardian?
Yes
If yes, an account will be verified/created
2nd Parent/Guardian Information
Parent/Guardian Name
*
First
Last
Email
*
Day Phone
*
Evening Phone
Same address as Parent/Guardian #1
*
Yes
No
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
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District of Columbia
Florida
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Hawaii
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
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State
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Alternate Contact
(If we are unable to reach a contact listed above)
Alternate Emergency Contact #1
*
First
Last
Relationship to Student
*
Alternate Emergency Contact #1 Phone
*
Alternate Emergency Contact #2
First
Last
Relationship to Student
Alternate Emergency Contact #2 Phone
Alternate Emergency Contact #3
First
Last
Relationship to Student
Alternate Emergency Contact #3 Phone
Are there any individuals who are NOT authorized to pick-up the student?
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If yes, please list names.
Please list names of any individuals not authorized to pick up the student
Medical Information
The student is covered by a medical insurance/assistance plan
*
Yes
No
Medical Insurance/Assistance Provider
Policy Number
Does the student have special considerations, learning needs, allergies, or medications that we should be aware of?
*
Yes
No
(please include any food allergies and/or bee stings)
Please explain:
*
Demographic Information
Which of the following best describes your student?
*
African American
Alaskan Native
Asian
Black
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Latine
Multiracial or Biracial
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Pacific Islander
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Other
Tell us more!
*
If additional information regarding ethnicity feels relevant for your student, feel free to share below. (Ex. Hispanic, Egyptian, Dominican, Somali, Pakistani, etc.)
Acknowledge and Agree to Registration Terms
Read & review
CTC Education & COVID-19 Policies
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I understand and accept the Medical Policy
Yes
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I have read and accept CTC's Education Policies
Yes
I have read and accept CTC's Education Policies.
*
Yes
I have read and accept CTC's COVID-19 Safety Policies.
*
Yes
Photo Release
*
For virtual sharings, photos and videos of students may be captured to share with camp families. These photos and videos will not be shared publicly unless permission is given below.
Yes, I give my permission for photos/videos of my child(ren)'s participation in CTC Education Programs to be used for promotional or grant development needs.
I DO NOT give permission for photos/videos of my child(ren) to be used for promotional or grant development needs. I understand photos and videos of my student will be taken and shared privately with families in individual camps as part of the celebration of the students work.
Email
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