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Magic for Muggle's Halloween Nights Registration
Please Make Sure To Fill Out A Separate Form For Each Child
Parent Last Name *
Your answer
Parent First Name *
Your answer
Child's Last Name *
Your answer
Child's First Name *
Your answer
Address *
Your answer
Child's Age as of June 1st *
Your answer
Parent Cell Phone (in case of emergency) *
Your answer
Email Address *
For Important Camp Updates
Your answer
Please Check Session Child Will Attend (October 12th is sold out!) *
Required
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
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Name of Physician *
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Physician Address
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Physician Phone Number *
Your answer
List Any Physical, Psychological, or Emotional Conditions
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List All Medications *
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Describe Any Activity Or Other Restrictions Including What Can Not Be Done
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Provide Any Additional Information About Child's Health That You Think Might Be Important
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Authorization *
This health history is correct and complete to the best of my knowledge. The Participant has permission to engage in all camp activities except as noted in this form. In case of emergency, camp directors may make necessary referrals to hospitals including but not limited to Mountainside Hospital, Montclair, NJ. I grant permission for transportation to and treatment at such local hospital or healthcare facility. I understand that any diagnosis, treatment, and/or transportation will be my sole financial responsibility. I agree to the disclosure to camp staff of the protected health information of the Participant. I grant permission for the release of such health information to non-camp healthcare providers who may need to administer treatment to Participant and permit the photocopy of this form for use in those situations. I also agree to the release of any records necessary for insurance or billing purposes. I give permission for a photocopy of this form to be used for the release of records.
Required
Refund Policy *
Refunds are only provided for cancellation when the space can be filled by another camper. Parents must notify camp directors two weeks in advance (unless there is a medical emergency).
Required
PLEASE NOTE, PAYMENT MUST BE PROCESSED TO HOLD CHILD'S SPACE. TO PAY, RETURN TO THE MAGIC FOR MUGGLES SUMMER DAY CAMP WEBSITE AND CLICK THE "PAY NOW" BUTTON TO PAY BY CREDIT CARD (or you can send a check). *
Required
Preferred Payment Method
Visit the register page to pay by credit card via PayPal or for directions to send checks
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