Arts-4-Autism Camp 
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Email *
Today's Payment:  *
Camper's Name *
Camper's Preferred Name
School Attending *
Date of Birth *
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Grade *
Parent's Name *
Parent's Phone Number *
Emergency Contact & Relationship to Camper *
Emergency Contact's Phone Number *
Please list any allergies (food, medicine, etc.) of the camper. 
Please list any food restriction for the camper. 
Please list any medical issue that may affect the camper's participation in activities. 
Please list any special accommodations for the camper. 
I give permission for my child, ______________________ , to participate in Coastal Harmony's 2023 Summer Camps. In the unlikely event of an emergency, I give my permission for my child to be treated by an accredited physician or dentist in an approved emergency clinic or hospital. I further agree to release, hold harmless, indemnify and defend Coastal Harmony and its employees and volunteers from any and all liability which may result from my child’s participation in this event. The parents or guardians understand that they are signing for the minor listed on the registration form and the signature is for both a medical and liability release.

We will have your completed form printed awaiting your signature on the first day of camp.
Parent Signature: _________________________________________________________       Date: _____________________
NOTE: You will receive emails and texts related to this camp. Your email and phone numbers will NEVER be shared with others. 
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