Camp Beautiful Registration Form
The Official Registration form for Spring Forward, The Beautiful Foundation, Inc.
Child
Name (First, Middle, Last) *
Your answer
Gender *
Your answer
School Name & Grade *
Your answer
Birthdate & Age (as of June 30, 2011) *
Your answer
Street Address *
Your answer
City, State & Zip Code (separated by comma) *
Your answer
Child's Home Phone# *
Your answer
Child's Shirt Size *
Parent/Guardian-Contact Info
Name (Mrs., Ms., Mr. First, Middle, Last) *
Your answer
Street Address *
Your answer
City, State & Zip Code (separated by comma) *
Your answer
Home Phone Number (use same # if all the same) *
Your answer
Work Phone Number *
Your answer
Cell Phone Number *
Your answer
Fax Number
Your answer
Email *
Your answer
Occupation/Employer *
Your answer
Parent/Guardian #2
Name (Mrs., Ms., Mr. First, Middle, Last)
Your answer
Street Address
Your answer
City, State & Zip Code (separated by commas)
Your answer
Home Phone Number (use same # if all the same)
Your answer
Work Phone Number
Your answer
Cell Phone Number
Your answer
Fax Number
Your answer
Email
Your answer
Occupation/Employer
Your answer
Child Lives With Whom? *
Your answer
Who is the Person Responsible for Payment? *
Your answer
Emergency Contact #1
First & Last Name *
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
Email *
Your answer
Relationship to Child *
Your answer
Emergency Contact #2
First & Last Name
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Email
Your answer
Relationship to Child
Your answer
Please list people in addition to the parent/guardian who can pick up the child from camp. *
Your answer
Medical Release Information
Insurance Information
Hospital Preference *
Your answer
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)
Medical Problem(s) with Required Treatment *
Your answer
Should a Paramedic be Called? *
Is your child presently being treated for injury or sickness, or taking any form of medication for any reason? *
If Yes please explain why.
Your answer
Does your child require a special diet? *
If Yes please explain why. (The purpose of the above listed information is to ensure medial personnel have details of any medical problem which may interfere with or alter treatment.
Your answer
In case of Medical Emergency *
Please separate by number and list all emergency contacts. (Name, Phone Number & Relationship to Child)
Your answer
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *
Parent/Guardian Initials
Your answer
I understand that the Beautiful Foundation, Inc. will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. *
Parent/Guardian Initials
Your answer
Please check how you heard about Camp Beautiful. *
Parent/Guardian's Electronic Signature *
Your answer
Date Signed: *
Your answer
Submit
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This form was created inside of The Beautiful Foundation Inc.