Winter Camp Enrollment Form
Information about Participant
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
School Grade
Age
Gender
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant's
Height
Weight
Hair Color
Eye Color
Primary & Emergency Contact Information
Primary Contact Name
First Name
Last Name
Relationship to Child
Mother
Father
Uncle
Aunt
Grand Parent
Family Friend
Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
DL#
Is the address same with the child?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Date & Times
Please select date(s) & time(s)
Monday 12/20 (7:30am-6:30pm)
Tuesday 12/21 (7:30am-6:30pm)
Wednesday 12/22 (7:30am-6:30pm)
Thursday 12/23 (7:30am-6:30pm)
Friday 12/24 (7:30am-6:30pm)
Monday 12/27 (7:30am-6:30pm)
Tuesday 12/28 (7:30am-6:30pm)
Wednesday 12/29 (7:30am-6:30pm)
Thursday 12/30 (7:30am-6:30pm)
Friday 12/31 (7:30am-6:30pm)
Participant Health Information
Primary Care Physician Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does the child have any medical conditions?
Yes
No
Please give details
Does the child have any allergies to food, medications, or insect bites?
Yes
No
Please give details
Medical Insurance Information
Insurance Company
Phone Number
Format: (000) 000-0000.
Policy
Policy #
Group #
Policy Holder Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agreement & Consent
I, parent/guardian of the participant, agree with the following statements:
I understand that I am responsible for paying every week my child is enrolled in the Winter Camp Program. Payment is due at time of registration.
I give permission that my child may be photographed, videotaped, and/or interviewed for the purpose of the Camp's promotional use.
I give consent for my child to be transported by the Camp for field trips or emergency care.
I have received and read a copy of the Camp Handbook. I have also received and read the Parent andCamper Code of Conduct.
Each child needs to bring their own lunch provided it does notneed heating or cooling, and is clearly labeled with the child’sname.
I understand that The Camp will not assume responsibility for any injury incurred while participating in athletic events,childcare programs, parent/child event and outings, special events, sports programs, or any related the camp sponsored activity.Certain risks of injury are inherent during participation in these programs and events. Nor will the the camp be responsible for any lost or stolen items while members and/or program participants are using the camp facilities, onthe camp premises, or on off-site camp program locations. I, the undersigned for myself and my heirs, do hereby release the camp and its employees and agents from any and all claims for injury, loss, or damage I may suffer as a resultof my participation. This includes any injury caused by negligence, if any, of the camp, its officers, employees, agents, volunteers,or the negligence of anyone else.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: