Juniata | Camp Registration

Options

Health Professions Institute Full Payment($1250)

Health Professions Institute Initial Deposit - Non Refundable($400)

Health Professions Institute Second Deposit($400)

Health Professions Institute Final Payment($450)

***Non-refundable fee of $400 included.***

*First Name:

*Last Name:

*Address:

*City:

*State:

*Zip:

*Parent E-Mail:

*Student E-Mail:

*Parent Phone Number:

*Student Phone Number:

*Emergency Phone Number:

*Birthdate:

*Grade in September:

Medical/Dietary Restrictions:

*Medical Insurance Carrier:

*Name on Policy:

*Policy Number:

*Payment Options (please note there is a 2.75% service charge for credit card payments):

Credit

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*Please click this option to agree to the Participant Agreement:

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