Number of Attendees*Name First Last Name First Last List Additional attendees Names here: Age of Camper*Diagnosis of Camper* Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dietary Needs and Allergies: Mobility Needs or Concerns: Would you like to perform for stage night?*YesNoAll acts can be no longer than a minute. No food, water, glitter, or any dyes are allowed in acts (facility requirements)Details of your act: What will you be performing, props you might need, what music you will bring, lighting and instrument needs, etc. (You can also email Beth Faller with these details once you have them, firstname.lastname@example.org)Campers can also help during stage night Stage Hands Lighting Assistant Sound Assistant Check the one(s) your camper is interested in: Stage hands (3-5 positions), Lighting assistances (1-2 position), and Sound Assistant (1 position).Anything else we should know? Add it here! I allow photos of my camper to be taken.* Yes No Photos can be used in marketing materials for Camp Korey. This includes print, social media and Camp Korey website use.