Chugachmiut Adventure Therapy Camp Registration
If you have any questions, please contact Becks Jacobs @
becksj@chugachmiut.org
or (907) 230-5184
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship
*
Please Select
Mom
Dad
Grandma
Grandpa
Aunt
Uncle
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Email
*
*Important camp information and updates will be sent to the email address on file.
2nd Parent/Guardian Name (Optional)
First Name
Last Name
Relationship
Please Select
Mom
Dad
Grandma
Grandpa
Aunt
Uncle
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Information
Child's Name
*
First Name
Last Name
Child's Gender
*
Please Select
Male
Female
Child's Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Child's Age
*
Is your child currently on Medicaid or Denali KidCare?
*
Yes
No
Is your child Alaska Native or American Indian
*
Yes
No
Any Known Allergies?
*
Yes
No
If yes, please list below:
Any Medications?
*
Yes
No
If yes, please list below:
Other Known Conditions *If none, please type N/A
*
Emergency Contacts
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Please Select
Mom
Dad
Grandma
Grandpa
Aunt
Uncle
Other
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Please Select
Mom
Dad
Grandma
Grandpa
Aunt
Uncle
Other
By submitting this form, I acknowledge that:
The information provided is accurate and complete. Chugachmiut Behavioral Health staff will be reviewing this registration application to determine eligibility and reaching out to schedule a behavioral health assessment if participant is not an established client.
Guardian Name
*
First Name
Last Name
Signature
*
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Submit
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