2020 Exchange Summer Camp Registration
Email address *
Name of Individual Completing the Form *
Relationship to Child *
Child Name *
Child's Date of Birth *
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/
DD
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How old is your child? *
What school does your child attend?
What grade are they going into? *
T-Shirt Size *
Primary Parent/Guardian Name *
Primary Parent/Guardian Phone Number *
Parent/Guardian Work Place
Secondary Contact Name
Secondary Contact Email Address
Secondary Contact Phone Number
Street Address *
HEALTH AND ALLERGY INFORMATION
Please ensure to fill out this information in it's entirety as it is EXTREMELY important.
Does your child have any known allergies? *
Required
If yes, what is he/she allergic to?
Is your child currently taking any medications? *
EMERGENCY CARE INFORMATION
Insurance Carrier *
Policy Number
Name of Child's Doctor *
Doctor's Office Phone Number *
Hospital Preference *
EMERGENCY CONTACT #1 (Name & Phone Number) *
EMERGENCY CONTACT #2 (Name & Phone Number) *
Parent/Guardian Alternate Pick Up (Up to 5) (Name and Phone Number) (Please separate the names using commas) *
SESSION SIGN UP
How often will your child be attending? *
Will you need EARLY DROP OFF or LATE PICK UP? *
Which one?
Clear selection
How did you hear about our camp? *
Any Other Comments?
Terms and Conditions
You agree that the operator may authorize the physician of his/her choice to provide emergency care in the event that neither you nor the family physician can be contacted immediately.

You hereby give The Exchange Summer Camp permission to transport your child by facility van/automobile/bus to field trips away from the facility upon acknowledgement of the activity. You understand that the facility will notify you each time your child is to participate in an activity that would involve transportation other than daily travel to and/or from the facility.

You hereby give The Exchange Summer Camp permission to photograph and video your child in the midst of Summer Camp activities. These photos and videos may be posted on our social media platforms, websites and email blasts.

You agree that you and your child(ren) will be familiar with and will abide by the rules and regulations set by The Exchange Summer Camp. You also accept responsibility for my child's actions while at The Exchange Summer Camp.

I understand and agree that in my child participating in The Exchange Summer Camp that there is a possibility of injury or other physical terms. I voluntarily agree, therefore, to assume all risks and responsibility for any such injury or accident that might occur while me or my child are in attendance at The Exchange Summer Camp. I further hereby voluntarily agree to waive my rights and that of my heirs and assigns to hold The Exchange Summer Camp, it's owners, agents, volunteers, assistants, employees, guest artists, faculty members and/or students liable for such damage, loss, injury or more. These Terms are between The Exchange Summer Camp and its affiliates and “you,” the individual completing this form. You agree that this form is like any written negotiated agreement signed by you.

BY CLICKING TO ACCEPT THE TERMS, YOU AGREE TO BE BOUND BY THE TERMS THAT APPLY TO YOU AS DESCRIBED ABOVE.
ACCEPT TERMS *
You must accept the terms of this agreement to submit your application.
Required
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