Summer Break Camp 2023 Registration form

Summer Break Camp 2023 Registration

3250 E. Allen Road, Tucson, AZ 85718
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 5-12 only.
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current TRAK Member?*

YesNo
Desired Camp Week: (Please note that you will be registered for all spots selected once payment has been received)*

Session 1 : May 29th-June 2ndSession 2 : June 5th-June 9thSession 3 : June 12th-June16thSession 4 : June 19th-June 23rdSession 5 : June 26th-June 30thSession 6 : July 10th-July 14thSession 7 : July 17th-July 21stSession 8 : July 24th-July 28thSession 9 : July 31st-August 4thSession 10 : August 7th-August 11th
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.
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!
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?*
Where did you hear about TRAK?*
Waiver and Release of Liability

This is MANDATORY
Waiver of Liability and Media Release
Waiver Signature*

Clear
Participant's Name*

First NameLast Name
List all participants covered by this waiver*
Media Release*

Yes, I grant TRAK permission to take and use photos of my child.No, permission to take or use photos denied.
Can we add you to our email list?
Stay in touch with news, special offers and updates.
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
Date*

MonthDayYear
Date
Should be Empty:

Summer Break Camp 2023 Registration

Demographic Information

Waiver and Release of Liability