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SUMMER CAMP REGISTRATION

News & Events

SUMMER CAMP REGISTRATION

Unit Name:

MEMBER INFORMATION

 

First Name
Middle Name
Last Name
Date of Birth:
Gender:
Ethnicity:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
EMail:

SCHOOL INFORMATION

 

School:
Grade:
Lunch Level:

MEDICAL INFORMATION

 

Doctor's Name and Telephone Number
Permission for Treatment by Doctor/Hospital:
Medical Issues
Does Member have any serious medical issues? (i.e., allergies, asthma, etc.)
If yes, please describe
This list should include all known allergies
Is Member currently on any Medications that EMT's may need to be aware of in the event of an emergency?
If yes, please list:

PHYSICAL INFORMATION

Skin Color/Features:
Height:
Weight:

HOUSEHOLD INFORMATION

Household Information
Member Lives With:
Annual Household Income
Number in Household:
Is there a Member of the Household 65 years old or older?
Is there a Member of the Household Handicapped?
Current Head of Household:
Current Single Parent:

*Primary Contact Name:
The primary contact will be the first person contacted with any concerns regarding member, member's account or in an emergency
Relationship to Member:
Information/Permissions
Select all that apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Contact Full Name
Relationship to Member:
Information/Permissions
Select all that apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Contact Full Name
Relationship to Member:
Information/Permissions
Select All That Apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Contact Full Name
Relationship to Member:
Information/Permissions
Select All That Apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Input your initials. Your initials will act as your electronic signature, indicating your consent and agreement to the terms of this application
Date

INFORMATION FOR SUMMER CAMP:

Back Pack Color - please select your child's first three choices of colors.  We will make every effort to ensure your child gets their choice of color; however, there are limited quantities of each.

Color - 1st Choice
Color - 2nd Choice
Color - 3rd Choice
T-Shirt Size
T-Shirt Size
Shoe Size
The registration fee is $15 per child.
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