SHINE! c
Camp Registration
Camp will begin July 6th and will end August 14th
Monday - Friday 9:30AM - 2:30PM
Early Morning Drop Off 8:30AM\
*** If a required quest DOES NOT apply to you or your child please type N/A***
What is child's name?
First Name, Last Name
Your answer
What parent or family has been or is currently incarcerated?
Required
Please type the name(s) of the incarerated family member(s)?
First Name, Last Name
Your answer
What is your child's gender?
Required
What is your child's race/ethnicity
Required
What is your child's date of birth?
MM
/
DD
/
YYYY
What is your child's address?
Include City, State and Zip Code
Your answer
What school does your child attend?
Your answer
What grade will your child enter in the fall?
What is your home phone number?
Your answer
What is your cell phone phone number?
Your answer
What is your child's cell phone number?
Your answer
PARENT/GUARDIAN INFORMATION
Mother/Guardian (1) First Name, Last Name
Your answer
Father/Guardian (2) First Name, Last Name
Your answer
What is your relationship to the child?
Your answer
What is your e-mail address?
Your answer
EMERGENCY CONTACT INFORMATION
Emergency Contact (1)
Your answer
Emergency Contact (1) Phone Number
Your answer
Emergency Contact (1) Address
Street, City and State
Your answer
Emergency Contact (2)
Your answer
Emergency Contact (2) Phone Number
Your answer
Emergency Contact (2) Address
Street, City and State
Your answer
PARTICIPANT HEALTH INFORMATION
All information will remain confidential: Please check all that apply
Required
If any of the above options are checked please elaborate.
Your answer
If your child uses an Epi-Pen:
Please check all that apply
Required
Does your child have any behavioral health concerns that we should be made aware of? If yes, please explain.
If you anserwed yes to the question above please elaborate below.
Your answer
If any, please list any medications that your child is currently on?
Your answer
Please list your child's medical insurer.
Your answer
Signature of Parent/Guardian
Your answer
Date
MM
/
DD
/
YYYY
Submit
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