Camp Registration Form

Child 1
Name*
First Middle Last
Gender*
- Female
- Male
School Name*
School Grade*
Date of Birth*
MM slash DD slash YYYY
Age*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Child’s Home Phone*
Child 2
Name
First Middle Last
Gender
- Female
- Male
School Name
School Grade
Date of Birth
MM slash DD slash YYYY
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Child’s Home Phone
Child 3
Name
First Middle Last
Gender
- Female
- Male
School Name
School Grade
Date of Birth
MM slash DD slash YYYY
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Child’s Home Phone
Child 4
Name
First Middle Last
Gender
- Female
- Male
School Name
School Grade
Date of Birth
MM slash DD slash YYYY
Age
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Child’s Home Phone
Parent / Guardian Contact Info #1
Name*
Prefix First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mobile*
Home Phone
Work Phone
Email*
Occupation
Employer
Second Contact Person Contact Info #2
Name
Prefix First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mobile
Home Phone
Work Phone
Email
Occupation
Employer
Child lives with:
Person responsible for payment :
Emergency Contact Information - Alternate Pickup/Release
Emergency Contact #1
Name*
Prefix First Last
Mobile*
Home Phone
Work Phone
Email*
Relation to child*
Emergency Contact #2
Name
Prefix First Last
Mobile
Home Phone
Work Phone
Email
Relation to child
Please list those people including in addition to parents/guardians who are permitted to pick up your child:*
Medical Release Information
Insurance Information
Policy Number
Name of Health Insurance Provider
Doctor
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Hospital Preference
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).
Medical Problem Required Treatment Should paramedic be called? Yes/No
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
- Yes
- No
Please explain:
In case of medical emergency contact:
Contact Name Phone Relationship to Child
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.*
Medical Action
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.
I understand that the Trenton Film Society or its Trenton Youth Filmmakers Mini-Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.*
Medical Expenses
I understand that the Trenton Film Society or its Trenton Youth Filmmakers Mini-Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.
Please select how you heard about the Carey Youth.
Terms of Agreement
Photo Release Agreement*
I agree to the Photo Release terms.
I hereby give permission for my child to be photographed during this Camp. I understand the photos may be used to keep a journal of activities, and for the purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed.
Transportation Release Agreement*
I agree to the Transportation Release terms.
I hereby give permission for the transportation of my child for official Camp activities by modes of transportation agreed to by the camp organizers.
Carey Baptist Church and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).
Parent/Guardian
First Last
Date
MM slash DD slash YYYY
Signature
Camp Registration Payment