Summer Day Program Registration
Child's Name
Your answer
Day Program(s) Attending
Required
Payment
Required
Membership Information
Parent(s) Name
Your answer
Address
Your answer
Parent Phone Number and email
Your answer
Emergency Contact other than Parent Guardian (name, relationship, phone)
Your answer
Participant Age, Birth Date, and Grade Entering in 2017
Your answer
Does Your Child Have Health Insurance
Insurance Provider and Group/Policy #
Your answer
Does your child have any medical conditions we should be aware of, including allergies?
Your answer
Does your child take any medications and if so, what kind?
Your answer
Permission for DNS to administer ibuprofin or benedryl if necessary
Anything else you would like us to know about your child?
Your answer
I will allow DNS to use pictures of my child taken at camp in promotional material.
Parental Release Agreement - By typing your name below you agree to these terms. I have been advised of and/or recognize the risk inherent with my child’s participation in this program. I assume full responsibility for all injuries that may arise from his/her physical or emotional limitations. I unconditionally release DNS and its employees from any and all liability or claims that may result from his/her participation in this program, unless the injury or damage is primarily the direct result of negligence of DNS or any of its employees and not caused in part by my child’s own negligence. This child has no health, emotional, or injury-related conditions (recent or chronic) which will be aggravated by or which will exclude his/her active participation in the program. This child has seen a physician in the last year. In case of injury or illness, I give permission for my child to be transported to and receive medical treatment at a local medical facility, and I guarantee the payment of all expenses incurred for such transportation and treatment.
Your answer
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