2019 Camp Kieve/The Leadership School Registration for 6th Grade Memorial Middle School
We are thrilled that your incoming 6th grader will be joining us at Camp Kieve's Leadership School from September 17-20th, 2019.

In order to pay the program fee and/or request a scholarship, please visit the Payment & Scholarship Information tab of our website at: https://www.spsd.org/our-schools/memorial-middle/for-families/camp-kieve/payment-and-scholarship

Participant's First Name *
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Participant's Last Name *
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Birthdate *
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Home Address *
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Phone Number *
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**Sex *
**Camp Kieve offers gender inclusive accommodations for students at the Leadership School. Please list your email address below if you would like to connect with a Kieve staff member about these housing options for your student.
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Parent/ Guardian Name *
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Day Phone Number *
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Evening Phone Number *
Your answer
Parent/ Guardian Email Address *
Your answer
Does your child have any special needs (educational, behavioral, medical, or dietary) that we should be aware of or take any daily medication?
Your answer
The medications listed below may be administered to your child on an as needed basis per Kieve-Wavus protocol and standing orders. If you wish your child to receive a medication that is not listed, including prescription medication, please complete the additional medication form. If you do not want your child to receive any of the listed medications, please select the "None of the above" box at the bottom of the list. *
Required
Family Physician's Name *
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Family Physician's Phone Number *
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Health Insurance Plan and Number *
Your answer
Parent/Guardian Authorization of Health Care *
Parent/Guardian Authorization for Health Care:This form is correct and accurately reflects the health status of the child. The child has permission to participate in all Kieve-Wavus activities except as noted by me and/or an examining physician. I authorize the Kieve-Wavus staff to provide routine healthcare, dispense medications, and seek emergency treatment for the child. I give permission to the physician selected by Kieve-Wavus to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for the child. I understand the information on this form will be shared on a “need to know” basis with Kieve-Wavus staff. I give permission to photocopy this form. In addition Kieve-Wavus has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Kieve-Wavus is not responsible for any medical costs incurred on behalf of the child. I give permission to Kieve-Wavus to use my son’s/daughters photo to publicize Kieve-Wavus programs.
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Terms Acceptance & Signature *
I, the parent/guardian completing this Participant form, warrant the truthfulness of the information provided in this application. (Please type your first and last name for your electronic signature.)
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Confirmation of Signature *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
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