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Team Randy Application Summer 2024
Please fill out this form in its entirety to apply for Team Randy, Summer 2024 Session. An immunization record must be filled out and emailed to TeamRandy1985@gmail.com in order for the application to be complete. Thank you!
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Email
*
Your email
Camper’s Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade (Fall 2023)
*
Choose
7th
8th
9th
10th
11th
12th
graduated
t-shirt size (adult)
XS
S
M
L
XL
XXL
Other:
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Home Address
*
Your answer
Parent/Guardian Name and Cell Phone
*
Your answer
Emergency Contact 1 (Name, Relation, and phone number)
*
Your answer
Emergency Contact 2 (Name, Relation, and phone number)
Your answer
Photo Release: Do you provide permission for Team Randy to use photographs of your child with or without his/her name and for any lawful purpose including, but not limited to: illustration, advertising, social media, and/or web content?
*
Choose
Yes. I permit Team Randy to use my child's photos.
No. I do NOT permit Team Randy to use my child's photos.
Medical Information
The following information will allow us to provide the safest summer for the children.
Physician's Name and Phone Number
Your answer
Preferred Hospital
Your answer
Special Needs if applicable:
Your answer
Special Education Classification if Applicable:
Your answer
What is something important that we should know about your child to ensure he/she has a fun and productive summer?
Your answer
What do you hope this teenager gains from Team Randy?
Your answer
Recent Injuries/Surgeries:
Your answer
Allergies:
Your answer
Medications that would need to be administered during camp:
Your answer
Consent for Medical: State law requires parents to sign the statement (only exception being religious beliefs). If you do not sign this statement, on the basis of religion, a separate waiver form must be signed.
I the parent/guardian of the above named child give permission to the physician selected by Team Randy to secure proper medical treatment in the event of an emergency.
I request a separate waiver on the basis of religion.
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Immunization form to be completed and sent via email.
Immunization Record
I have emailed a copy of the immunization form to
TeamRandy1985@gmail.com
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