Secondary Diagnosis, if any: Please provide detailed information regarding the diagnoses that will help us work with the rider effectively (box will expand if more room is needed): Health Information: Rider Food Allergies, if any: Please explain any health/medical conditions or health concerns and any special instructions (box will expand if more room is needed): Choose A Session: Please number each session in order of preference (i.e. 1st, 2nd 3rd). Only mark the sessions you are able to attend: Session #1: 8:30 am 9:45 am – Session #2: 10:05 am 11:20 am – Session #3: 11:40 am 12:55 pm – Session #4: 2:00 pm 3:15 pm – Session #5: 3:35 pm 4:50 pm – Payment Information: Payment of the camp fee is required to process the registration form. Please include check of $150 payable to Down Syndrome Association of Greater St. Louis OR complete below Credit card information: Name on Credit Card: Credit Card #: Expiration Date: Security Code: Rider Information:
Secondary Diagnosis, if any: Please provide detailed information regarding the diagnoses that will help us work with the rider effectively (box will expand if more room is needed): Health Information: Rider Food Allergies, if any: Please explain any health/medical conditions or health concerns and any special instructions (box will expand if more room is needed): Choose A Session: Please number each session in order of preference (i.e. 1st, 2nd 3rd). Only mark the sessions you are able to attend: Session #1: 8:30 am – 9:45 am Session #2: 10:05 am – 11:20 am Session #3: 11:40 am – 12:55 pm Session #4: 2:00 pm – 3:15 pm Session #5: 3:35 pm – 4:50 pm Payment Information: Payment of the camp fee is required to process the registration form. Please include check of $150 payable to Down Syndrome Association of Greater St. Louis OR complete below Credit card information: Name on Credit Card: Credit Card #: Expiration Date: Security Code: Rider Information:
STL-Rider-Registration-Form-2016.docx