F.I.T. Kids Camp February Break 2016

Program Registration ** All Information is Confidential **

Child’s Full Name (please complete one form per child):

_____________________________________________________________

Birthday: _____ /_____ /_____ Grade entering in the Fall: ________ Age at time of program: ____

Street Address: ________________________________ City: _____________

State: ____ Zip: _______

Home Phone: (_____)_______ - _________ Contact E-mail (please print):__________________________

Father’s Name or Legal Guardian's Name: ____________________________________________

Mother’s Name or Legal Guardian's Name: ___________________________________________

Emergency Contact Information:

Parent or Guardian Emergency Contact Phone Numbers - during program hours:

Dad – Home (_____)_______ - _________ Mom – Home (_____)_______ - _________

Dad – Work (_____)_______ - _________ Mom – Work (_____)_______ - _________

Dad – Cell (_____)_______ - _________ Mom – Cell (_____)_______ - _________

Alternate Emergency Contact Name(s) and Relationship to Camper:

Name: ______________________________________________

Relationship: _________________________________________

Phone (specify):H/W/C (_______)_______ - ___________

Does your child have any medical (i.e. allergies, overheating issues), physical, psychological, or social concerns that we should be aware of?

_______________________________________________________________________________

Does your child take regular medication?_______ If yes, what medication(s)?

_______________________________________________________________________________

Does your child have any food allergies?

_______________________________________________________________________________

Physician Name: ______________________________________________

Phone: (_______)________-____________

Is your child covered by health insurance? _____ Yes _____ No

Insurance Company: _______________________ Policy Number: _______________________

Waiver and Medical Release:

I approve the application above and conditions listed below. I have written/attached any necessary and pertinent information concerning our family and our child. I release F.I.T. gym and Lora Downie, Health Coaching Services, the staff and volunteers for F.I.T. Kids Camp, its affiliates, other volunteers and employees of all responsibilities for any injuries, to body or property, which may occur to my child during the course of these activities. I give my permission for my child to be given first aid in case of any emergency while he/she is at F.I.T. Kids Camp. In the event that I cannot be reached in an emergency, I hereby give permission to the staff and volunteers to secure proper treatment for my child (after first attempting to contact father, mother, guardian, emergency contact and child’s physician).

Signature of Parent or Guardian _____________________________________________

Date _____________

Photography Release ___ I give ___ I do NOT give

my permission for my child to be photographed while at camp and for those photos

to be used promotionally.

Signature of Parent or Guardian _______________________________ Date

_____________

Child Pick-Up

The persons listed below have my permission to pick up my child from F.I.T. Kids

Camp. I understand ID may be required. (Please list all, excluding yourself):

_________________________________ ________________________________

The persons listed below are forbidden to pick up my child from F.I.T. Kids Camp:

_________________________________ ________________________________

Signature of Parent or Guardian ______________________________

Date _______________

Cancellation Policy: Any cancellation made 7 days prior to Day 1 of camp will receive a full refund.

Payment must be made with registration to hold your spot(s). Payment may

be made by credit card or check. Return registration form(s) to Anne Osovski or Lora Downie.

Credit Card Payments:

Name as it appears on your card:________________________

Credit Card (circle): Visa MasterCard Amex     Credit Card #:_________________________________

Exp Date:___/_____ Security Code: ______

{all credit card information will be kept confidential and shredded immediately after processing}

F.I.T. Kids Camp schedule:

February 16 & 18, 2015, 1 p.m - 4 p.m.

Cost: $65 for one child ($50 for each additional child)

Ages: 6-11

Camp location: F.I.T. Gym 465 W. Commercial St., East Rochester, NY 14620

Questions? Contact us!

Camp Directors: Anne Osovski: anne.getyoursweaton@gmail.com & Lora Downie: lora.downie@gmail.com