Leeds Met Carnegie Weight Management

About the Camper

First Name:

Camper's first name. (Required) 

Surname:

Camper's surname. (Required) 

Camper's gender:

---Select gender--- Male Female Select the camper's gender. (Required) 

Camper's date of birth:

Please enter as dd/mm/yyyy. (Required) 

Height:

Use metric or imperial units. (Required) 

Weight:

Use metric or imperial units. (Required) 

Camper's t-shirt size:

--- Select a size --- Small Medium Large XL XXL XXXL Tuition includes a Camp Tshirt. Please indicate size.Select a value from the dropdown list (Required) 

Doctor's name:

Applications are subject to approval from your child's Doctor, who we will contact.(Required) 

Doctor's Address:

Doctor's Address Line 2:

Doctor's Postcode or Zip:

Doctor's Phone:

(Required) 

Specify any other dietary needs:

Use this space to tell us about any other dietary requirements (Optional) 

Camper’s medical details

Medical requirements information:

Use this space to tell us about any medical requirements listed (Optional) 

Parent or guardian’s details

Title:

--- Select title --- Mr Mrs Miss Ms Other, please specify (Required) Select a value from the dropdown list (Required) 

First Name:

Parent or Guardian's first name. (Required) 

Surname:

Parent or Guardian's surname. (Required) 

Relationship:

Parent or Guardian's relationship to the camper. (Required) 

 

Second Parent or Guardian

Title:

--- Select title --- Mr Mrs Miss Ms Other, please specify Select a value from the dropdown list (Optional) 

First Name:

Second Parent or Guardian's first name. (Optional) 

Surname:

Second Parent or Guardian's surname. (Optional) 

Relationship:

Second Parent or Guardian's relationship to the camper. (Optional) 

How we should contact you

Address Line 1:

Enter your address. (Required) 

Address Line 2:

Address Town or City:

Address Postcode or Zip:

Email Address:

Enter your email address. For example, yourname@example.com (Required) 

Primary Phone:

Enter the phone number you'd prefer us to use to contact you. (Required) 

Work Phone:

(Optional) 

Home or Other Phone:

(Optional) 

Use this as your billing address (if paying now)

If paying by credit or debit card, check this box to copy to your billing address.