Kids Camp Registration Form
Complete and sign separate forms for each child participating in Kids Camp.
Camper’s Full Name *
Camper's Age *
Birthdate *
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Gender
Clear selection
Full Name Parent/Guardian *
Parent/Guardian Primary Phone Number *
Emergency Contact/Authorized Pick-Up (Full name and phone number
Emergency Contact/Authorized Pick-Up (Full name and phone number
Grade in school next year *
Family Mailing Address (Street, City, State, Zip) *
Doctor: *
Doctor's phone: *
Medical/Hospital insurance: *
Policy or Group # *
Attendance- Check Weeks that you would be interested in sending your child(ren) to camp. (You do not have to sign up for weeks at a time. If you would like to send your child a day or a couple of days a week that is completely fine.)
If successful would you be interested in more weeks? (These weeks will depend on the number of families interested.)
Date of last Tetanus Shot *
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ALLERGIES: (Check all that apply)
Other health conditions (Check all that apply)
Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to any of the health conditions. Also, indicate any activities to be discouraged or restricted. Attach a separate sheet if needed
CONSENT OF PARENT/GUARDIAN. This health history is complete and accurate. I know of no reason(s), other than the information indicated on this form, why my son or daughter should not participate in prescribed activities except as noted. I authorize all medical, diagnostic and hospital procedures which may be performed or prescribed for my child by a licensed physician, when efforts to contact me are unsuccessful and when deemed immediately advisable by the physician to safeguard my child’s health Initial *
I have read all of the Kids Camp registration information. I understand the information and agree to abide by the terms. I give my permission for my son or daughter to attend Kids Camp and participate in all phases of activities. I agree to instruct my child to observe rules and regulations governing the activities. I understand that a statement of good health is required before he or she may attend. I hereby release Kids Camp and Asheville Pisgah Christian School and all staff members from all liability for any injury sustained by my child apart from negligence on the part of camp or a staff member. I also give permission for my child to be photographed and videotaped, and further agree to allow Kids Camp to use these pictures for promotional purposes. *
I agree to pay at the beginning of each week for the days that my child will be attending, this includes post-care. *
I also understand that my account must be kept up to date or my child may not attend Kids Camp until it is current. *
I understand that my insurance coverage for my child will be used as the primary insurance in the event medical intervention is needed. *
I understand that if my child has on-going behavioral problems that are not being resolved, Kids Camp staff and Asheville Pisgah Christian School reserve the right to suspended or terminate my child from the program. *
I understand that although APCS Kids Camp has taken state recommended steps to operate safely, the nature of childcare, the facilities and the people involved, it is not possible to entirely eliminate all risk of COVID-19 or other contagious illnesses. I understand the assumption of risk that I am making and will not hold APCS Kids Camp liable. *
Parent/Legal Guardian Signature *
Date *
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