Camp Level Up Registration

Camp Level Up Registration Form

Please complete the form and payment below. If you have any questions please email alison@mesaadi.org

Step 1 of 2

Parent Name *

First

Last

Parent Phone Number *

Parent Email Address *

Student Name *

First

Last

Student's School District *

Student Age as of June 1, 2023 *

Emergency Contact Name *

First

Last

Other than parent

Emergency Contact Phone *

Second Emergency Contact Name *

First

Last

Other than parent

Second Emergency Contact Phone *

Dietary Restrictions *

Allergies *

Does the student utilize any mobility aids? *

Will the student require after care? *

After care will begin at 12:00 PM and end at 4:00 PM

Additional Information

Click to Agree

I Agree

By attending Camp Level Up, you understand the student may be photographed, filmed, or videotaped and you hereby give Mesa Regional Foundation for Accessibility, Diversity and Inclusion the right to take pictures and/or recordings of the student and grant the perpetual right to use the student’s likeness, image, photo (collectively, “image”) without compensation, for broadcast or exhibition in any medium and to put the finished pictures/recordings to any legitimate use without limitation or reservation. You hereby waive, and forever release Mesa Regional Foundation for Accessibility, Diversity and Inclusion from and against any and all claims or actions arising of or resulting from any use of the student’s image. Mesa Regional Foundation for Accessibility, Diversity and Inclusion shall not be obligated to use, and may elect not to use, the student’s image.

Camp Level Up Registration Form

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