BlackRock Summer Camp Youth Art Academy | Student Information Form
Please note that updates to the health and safety policy will be distributed in the weeks leading up to program start dates to ensure guidelines and safety protocols adhere to the most recent CDC and Maryland State Health Department regarding Covid 19. A revised Camper Handbook will also soon be available.
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Primary Household Email
Secondary Email
Camper Last Name
Camper First Name
Birthdate
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Preferred Family Contact (First and Last name)
Preferred Family Contact (Phone Number)
Grade Attending in Fall 2021
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Enrolled Session for Camper Listed:
School Attending in Fall 2022
Primary Family Physician (First and Last name)
Primary Family Physician (Phone number)
Date of last Tetanus shot
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DD
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YYYY
Does the Camper have any allergies?
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Please list any camper allergies
Please list any medications taken during the day *Medications must be accompanied by Medication Authorization Form available for download on website
What is the name of your health insurance provider? (Aetna, Blue Cross, etc.)
We are required by Montgomery County Department of Health and Human Services Licensure and Regulatory Services to have updated Immunization records for all campers. Note that if your child attends a licensed public or private school in Maryland, you do NOT need to provide BlackRock with a copy of your immunization records. Does your child attend a Maryland licensed public or private school or day care in the state of Maryland?
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Are there any special conditions and/or disabilities or specific treatment your child requires of which you feel BlackRock needs to be aware? This information will be kept confidential and is extremely helpful for us in preparation for camp and to ensure your camper has a great experience. All BlackRock camps are inclusive and information provided here will not impact their enrollment.
Are there custody concerns of which BlackRock should be made aware?
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Individual granted permission to pick-up camper - #1 (Include First and Last Name)
Individual granted permission to pick-up camper - #1 (Phone Number)
Individual granted permission to pick-up camper - #2 (Include First and Last Name)
Individual granted permission to pick-up camper - #2 (Phone Number)
Camper T-Shirt Size
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I grant BlackRock permission use of photography/video of my child to inform and communicate details of this class with the public through social media, BlackRock website and newsletter.
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I understand that a Camp Handbook and additional safety protocols will be communicated and implemented in the weeks and days leading up to my child's program start date.
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I understand that camp is a nut-free setting.
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I understand that my child will need to bring a non-perishable lunch and snack each day to camp.
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I have read and understand the cancellation and refund policy on the website.
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