Mini Camps Youth Enrollment Youth Member’s Name * Youth Member's Name First First Last Last Youth Member’s Age * Youth Member’s Current Grade * Gender Parent’s Name * Parent's Name First First Last Last Parent’s Phone * Parent’s Email * Youth Member’s Physical Disability * Amputation Cancer Cerebral Palsy Deaf or Hard of Hearing Diabetes Epilepsy/Seizure Disorder Heart Condition Multiple Sclerosis Muscular Dystrophy Obesity SCI Spina Bifida Visually Impaired OtherOther Will youth member need an ASL Counselor? * Yes No Youth Members Goals * Days Attending October 18 October 19 October 20 October 18-20 Today’s Total * If you are human, leave this field blank. Submit
