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Virtual Camp Registration Form
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Child's Name
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Date of birth
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Age
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School
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Grade just finished
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Address
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School Lunch Status
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Special Education Status
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Limited English Status
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Child lives with
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Parent 1 Name
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Parent 1 Address
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Parent 1 Cell Number
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Parent 1 Email
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Parent 2 Name
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Parent 2 Address
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Parent 2 Cell Number
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How did you hear about this camp
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Food Allergies
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Do you have a device with video and internet connection?
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Consent and Release Statement: When I receive a copy of the Bethune Institute/ Pleasant Green Family Handbook upon enrollment of my child in the program, I agree to abide by the policies and procedures described therein. I will provide Bethune Institute with a copy of my child’s report card. I give Bethune Institute/Pleasant Green permission to access and keep copies of my child’s academic record, including report cards, standardized test scores, IEP, ELL, Special Education and other records. This permission will extend for a year. These scores will be kept confidential and only be used by our program for the purpose of program planning and group analysis, as well as to evaluate the overall impact of the program to obtain continued funding for the program. I give Bethune Institute/Pleasant Green permission to notify me using the contact information above (telephone, email, mail or telephone) about the status of my child’s enrollment, attendance, upcoming summer program events, schedule changes and program updates.I certify my understanding that I will be required to sign a Field Trip Permission Form to authorize my child’s participation in any field trip planned by the program and that alternate care will not be provided should I choose not to grant such permission for my child’s participation. Additionally, I acknowledge that my child’s participation in Field Trips is at the discretion of the program staff. I give permission for Bethune Institute/Pleasant Green to transport my child by church van or other contracted transportation to designated field trips.I give permission for my child to be included in the documentation of Bethune Institute/Pleasant Green including photographs, audio/visual recordings, and reproductions of academic work, participation in surveys, and written quotations or descriptions of activities. I also understand that resulting materials may be exhibited before the community, fundraising, or other groups and individuals. I give permission for the Participant to participate in any and all activities, including transportation (if needed) to and from Camp for camp field trip activities, except those specifically prohibited by the participant’s physician or parent/legal guardian. I understand that if a medical emergency arises, program staff will take all steps necessary to ensure my child’s safety and will call, if necessary, a public emergency vehicle to transport my child to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred.I hereby certify that I have read and do understand the above information
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By entering your initials in the box below, you acknowledge that you are the parent/guardian of the child above and are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
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