Recipe For Success Summer Camp Registration Survey

Which session would you like your camper to attend?

June 11-15: Marco Polo Discover tastes and cultures from Marco Polo's journey along the Silk Road

June 18-22: Eat This! Create a wacky store-ready food product, then put it on the shelf!

July 9-14:Super Foods Heros come to life through recipes and comic strips while creating a super you

Choose your camp:

Please tell us about your camper: (Required.)

Name:

Prefer to be called:

Age:

Date of birth:

School name:

Have you ever participated in a Recipe for Success program?(Required.)

If yes, which camp and what year?

Parent/Guardian Contact Information: (Required.)

Parent Name(s):

Email Address:

Cell Phone number:

Work Phone number:

Street address:

City, State, zip code:

Non-parent or guardian Emergency Contact:(Required.)

Name :

Home Phone:

Cell Phone:

Relationship:

Name:

Home Phone:

Cell Phone:

Relationship:

OTHER ADULTS PERMITTED TO PICK UP MY CAMPER:

HEALTH CONCERNS

Is the camper on a special diet?(Required.)

Yes

Please describe

Please list the foods which your camper should avoid, as well as those that are permissable

Foods to Avoid

Foods Permissable, or exceptions

Please list any allergies to the following, and any treatment needed after exposrure. (Required.)

Insects

Food

Plants

Medications

Other

Physician's Information (Required.)

Name:

Phone Number:

Please share with us any information about your child that will help us create a positive and supportive environment for them:

**Events that occurs at home that may affect your child at camp are important to have communicated to camp staff. Please inform the Camp Program Director in confidence so that your student can be cared for compassionately and with understanding.Thank you!

Please share with us how you found our program: (Required.)

FOR QUESTIONS, CONTACT:
Justin Kouri: justinkouri@recipe4success.org
713-520-0443

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Recipe For Success Summer Camp Registration

CHOOSE YOUR OWN DELICIOUSLY FUN FOOD ADVENTURE!