Fall/Winter Break Camp Registration form

Fall/Winter Break Camp Registration

3250 E. Allen Road, Tucson, AZ 85718
Desired Camp Dates:

Please only select specific dates if you intend to pay for them in full. Payment link can be found on our web page next to registration tab. Payment must be made in order for slot to be secured. For those who are applying for a scholarship please select the "scholarship needed " tab.
Desired Camp Dates:

Fall Break Camp - October 6th -10thWinter Break Camp - December 22nd - 26th (Will not have camp Christmas day)Winter Break Camp - December 29th - January 2nd (Will not have Camp New Years Day)
Camper Information
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
This camp is for ages 5-14 only.
Gender*

MaleFemale
2nd Camper's Name

First NameLast Name
Birth Date

MonthDayYear
Age
This camp is for ages 8-14 only.
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current TRAK Member?*

YesNo
Are you acitve duty or a veteran?

YesNo
Parent/Guardian Information
Parent #1 Name*

First NameLast Name
Cell Number*

Area CodePhone Number
Parent #2 Name*

First NameLast Name
Cell Number*

Area CodePhone Number
Home Number

Area CodePhone Number
Best E-mail*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Hospital/Clinic Preference*
Physician's Name*
Physician's Phone*
Insurance Company*
Please enter your Insurance Provider. This is required for child to attend camp.
Policy Number*
Please enter your Insurance Policy Number. This is required for child to attend camp.
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.*
If none, please just say no.
Is the camper prescribed an inhaler or insulin? If yes, please explain any instructions.
Are there any behavioral patterns or concerns we should know about?*
Demographic Information

TRAK relies on grants to support its programs. Grantors frequently ask us for the following information, and your response is completely optional. Thank you!
Where did you hear about TRAK?*
Waiver of Liability and Media Release
Waiver Signature*

Clear
Media Release*

Yes, I grant TRAK permission to take and use photos of my child.No, permission to take or use photos denied.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Should be Empty:

Fall/Winter Break Camp Registration

Desired Camp Dates:

Demographic Information