Preschool Summer Camp Enrollment Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Camper's Photo (Optional)
The parents/guardian listed below will be the authorized person to pick-up the child after the camp.
The parents/guardian listed below will also be the primary emergency contact person.
Does the child have any allergies? If yes, please list them below:
Does the child have any previous injuries? If yes, please explain them below:
Does the child have any current medical conditions? If yes, please list them below:
Does the child takes any medication? If yes, please list them below and explain its purpose:
Method of Payment
( X )
Register for one week only
Register for two weeks only
Register for three weeks only
I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached. I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
I released the organizers, coaches, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment.
I confirm that all information given in this form is true, complete, and accurate.
Should be Empty: