Art In Motion Camp 2018
Please complete by Friday, August 17. If you have any questions, please email kylie@localmotionproject.org Thank you! ~UpCycle and Local Motion Project.
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Child's First Name *
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Child's Last Name *
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Child's Age *
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Child's Date of Birth
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Choose the week(s) your child is attending camp: *
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Enter your mailing address. *
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Parent/Guardian #1: Name *
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Parent/Guardian #1: Phone Number *
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Parent/Guardian #1: Email Address *
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Parent/Guardian #2: Name
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Parent/Guardian #2: Phone Number
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Parent/Guardian #2: Email Address
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Additional Emergency Contact: Name *
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Additional Emergency Contact: Phone Number *
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List additional adults who are authorized to pick up your child from camp. Include name, phone number, and relation to child.
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Does your child have any allergies that we should be aware of? If yes, please describe symptoms and action plan. *
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Does your child have any food restrictions? If yes, please explain. *
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Does your child take any medication that needs to be administered during camp hours? If yes, please explain. *
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Are there any activities in which your child should not participate or will need extra help to complete? If yes, please explain. *
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Photo/Media Release. Select one. *
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Parent/Guardian Authorization - This emergency information and health history are correct to the best of my knowledge, and the participant described herein has permission to engage in all activities, except as noted above. I, as the parent/guardian, authorize Local Motion Project and UpCycle Creative Reuse Center personnel to seek emergency treatment as required and/or to transport my child to the appropriate medical facility in the event that urgent/emergency care is necessary. The hospital and its medical staff are authorized to provide any treatment, which is necessary for the well being of my child. I understand that minor accidents or injuries will be treated on-site and that I will be notified of any such incidents and the treatment administered. I understand that specific participant information may be shared with limited staff as may necessary and will be regarded as confidential. I agree to hold Local Motion Project and UpCycle Creative Reuse Center and their officers, directors, members, staff and agents harmless for any injury to person or property not caused by negligence of the organization. *By typing my name below, I agree to the above authorization* *
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