Summer Camp Registration Form

Childs Information

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

School

Grade Entering

Age

Date of Birth

Gender

Primary Email Address

Dietary Restrictions

Does your child have any allergies and/or intolerances to food, medication or any other substances? What are the symptoms and action to be taken if any?

Parent/Guardian Information

Please fill out your contact information below.

Parent/Guardian Name*

First Name

Last Name

Phone

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Place of Employment

Work Phone*

Primary Email Address

Emergency Contact

Name

First Name

Last Name

Phone

Relationship to Child

Medical Information

Name of Insurer*

First Name

Last Name

Insurers Phone

Subscriber Name

First Name

Last Name

Subscriber Date of

Subscribers Relationship to Child

Parent Guardian Other

Group Number

Policy Number

Additional Information

Authorized Person for pick-up (in addition to parents and emergency contacts)*

First Name

Last Name

Person(s) NOT authorized for pick-up (appropriate legal paperwork must be on file when the custodial parent requests not to release the child to the other parent)

First Name

Last Name

Please provide information on any chronic physical problems and pertinent developmental information and any special accommodations needed. Attach additional sheets if necessary.

Will your child be required to take medication during the camp day? If so, please complete Medication Authorization Forms

Yes No

Parent/Guardian Signature

[clear]

Use your mouse or finger to draw your signature above