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Fantastic Beasts Summer Day Camp Registration 2020
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 2019 *
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 (we are only offering one session) *
This session will run from 9AM to 1PM daily.
Required
Emergency Contact Name *
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Emergency Contact Phone Number *
Your answer
Name of Physician *
Your answer
Physician Address
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Physician Phone Number *
Your answer
List Any Physical, Psychological, or Emotional Conditions
Your answer
If Participant Has Ever Been Hospitalized Or Had Operations, Please Describe
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List All Medications *
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List All Serious Injuries
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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.
Required
How did you hear about us?
To pay, please return to the Fantastic Beasts Registration page on the website and click "Click Here to PAY". PAYMENT MUST BE MADE IN FULL TO SECURE YOUR CHILD'S SPOT. *
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