Winter Camp Excellence Registration Form
We're looking forward to an awesome time at WINTER CAMP EXCELLENCE this December! Please read and complete ALL of the following questions.
Email address *
Child's Name *
Your answer
Child's School *
Your answer
Grade Level *
Your answer
Teacher's Name *
Your answer
Gender *
Birthdate *
MM
/
DD
/
YYYY
Ethnicity - Select all that apply. *
Child's Home Address *
Your answer
City, State, Zip *
Your answer
My child will: *
Required
T-Shirt Size *
Select the week/s attending camp *
Required
Is your child attending tutoring or ESY in the am? *
Campers will participate in one (1) program during the afternoon. Here are the program options: ART, COOKING, RAP & DJing, DRUMMING, CHEERLEADING & our most recent addition CAPOEIRA, a very cool form of Afro-Brazillian Martial Arts! Please select three program choices - placing a #1 next to your first choice, #2 next to your second choice, and #3 next to your 3rd choice. Placements are made on a first come, first serve basis. *
Your answer
EMERGENCY CONTACT INFORMATION
Mother/Legal Guardian’s Name *
Your answer
Best Contact Number *
Your answer
Email Address *
Your answer
Father/Legal Guardian’s Name *
Your answer
Best Contact Number *
Your answer
Email Address *
Your answer
Additional Emergency Contacts: Please list two more names and phone numbers *
Your answer
List name and phone numbers of two more people to whom the student may be released: *
Your answer
MEDICAL CARE INFORMATION
Student Physician/Medical Care Provider *
Your answer
Physician Address *
Your answer
Physician Phone Number *
Your answer
Health Insurance & Policy Number *
Your answer
Please List All Allergies or Medical Concerns (below): *
Your answer
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? *
Is your child allergic to any type of food or medication? *
Does your child require a special diet? *
Please provide an explain of all questions answered "yes" from above. *
Your answer
Please list any medications that your child will bring to camp and include dosage times and amounts *
Your answer
SIGNED RELEASES
Provide your permission by putting your initials next to each statement below.
Field Trip Permission: Camp Excellence has permission for my child to take fields trips with Camp Excellence. *
Your answer
Transportation Permission: Camp Excellence has permission to transport my child to and/or from school, on field trips and at Camp Excellence campsite. *
Your answer
TV, Video, and Computer Use: My child may, as part of a scheduled activity, watch educational and/or program-based programs, music and movies during the day and/or as a computer for up to one hour per day. *
Your answer
Photo Release: Camp Excellence has permission to photograph my child. I understand the photos will may be used during presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I do not expect compensation, and all photos are the property of Camp Excellence and its affiliates. *
Your answer
Personal Property: Camp Excellence is not responsible for lost or damaged personal property. *
Your answer
First Aid Permission: Camp Excellence staff has my permission to administer basic first aid to my child when needed. I also understand that I will be informed of any injuries attained by my child when I pick him/her up from the program. *
Your answer
Emergency Medical Permission: The health history provided is correct and complete to the best of my knowledge and the camper described has permission to engage in all camp activities except as noted on the registration forms. I give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. All important medical information for my child has been documented on the medical and individual care plan forms. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above. This form may be photocopied for trips out of camp. In the event that I cannot be reached in an EMERGENCY, I give permission to the physician selected by the program director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. *
Your answer
ACCEPTANCE
PLEASE READ THE FOLLOWING STATEMENT AND PROVIDE YOUR INITIALS IN THE SPACE BELOW IN APPROVAL.
I have reviewed this form, and understand and agree to all of the terms presented in this document. I agree to report any issues or concerns my child shares with me regarding their experience in the program. I understand that Camp Excellence works to ensure all children are safe and comfortable while at the Camp Excellence and that the Camp Excellence’s staff will work to resolve issues quickly when they are shared.
Your answer
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