2018-2019 BASE Camp Registration Form
Please complete a separate form for each child attending.
Email address *
Student's Last Name *
Your answer
Student's First Name *
Your answer
Date of Birth *
MM
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DD
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Age *
Your answer
Grade *
Your answer
Teacher *
Your answer
School *
Gender *
Address *
Your answer
City *
Your answer
Zip *
Your answer
County *
Your answer
Township *
Phone *
Your answer
Please list any medical conditions or allergies (including food allergies) *if food allergy exists, we must have a Dr.'s note on file stating the particular allergy and any necessary substitutions*
Your answer
Lunch Status of Student (Please choose one) *
Race/Ethnicity (Check all that apply) *
Is student disabled? *
If student is disabled, please list type of disability.
Your answer
Transportation from BASE Camp *
Total Number of Adults in Household
Your answer
Number of Children in Household Under 18
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian City *
Your answer
Parent/Guardian Zip *
Your answer
Parent/Guardian Home Phone *
Your answer
Parent/Guardian Work Phone
Your answer
Parent/Guardian Cell Phone
Your answer
Parent/Guardian Relationship to Student *
Your answer
Parent/Guardian Occupation
Your answer
Parent/Guardian Marital Status
Parent/Guardian Employment Status
Parent/Guardian Highest Level of Education
Is student currently in foster care? *
Primary Language Spoken at Home
Your answer
Emergency Contact 1: Name *
Your answer
Emergency Contact 1: Phone *
Your answer
Emergency Contact 1: Relationship to Student *
Your answer
Emergency Contact 1 (listed above) is authorized to pick up student? *
Emergency Contact 2: Name
Your answer
Emergency Contact 2: Phone
Your answer
Emergency Contact 2: Relationship to Student
Your answer
Emergency Contact 2 (listed above) is authorized to pick up student?
Emergency Contact 3: Name
Your answer
Emergency Contact 3: Phone
Your answer
Emergency Contact 3: Relationship to Student
Your answer
Emergency Contact 3 (listed above) is authorized to pick up student?
Additional Individuals Authorized to Pick-Up Student
Your answer
Emergency Medical Care-I hereby state that I am the parent/guardian of a minor, who resides with me at the provided address. I authorize anyone who is authorized to represent SCLC at an approved SCLC function, to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the continental USA. It is understood that this is for emergency medical treatment in the event that I am unable to be contacted. *
Child's Doctor *
Your answer
Preferred Hospital for Emergency Medical Care *
Your answer
I hereby consent to photographs, videos, motion picture films, and/or biographical information for which my child posed, and/or writings and/or audio recordings made of my child's voice to be used by Steuben County Literacy Coalition (SCLC), in whatever way they deem necessary for communication, media relations and advertising, which may include, but is not limited to, print media, television, SCLC collaterals, SCLC advertising and SCLC website; furthermore, I hereby consent that such photographs, films, recordings or writings and the plates, tapes or discs from which they are made shall become the property of SCLC. SCLC shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, writings, plates, tapes and disks as they deem necessary, free and clear of any claim whatsoever on my part. *
I have read the attached disclosures and releases of information, in regards to program policies and consent to all statements below. *
Captionless Image
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By typing my name below, I agree that I am signing this document as the parent or guardian of the child above. *
Your answer
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