Clone of Summer Camp Detailed Registration Form

Camper's Information

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Camper's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade(going into)*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Mother Information

Name*

First NameLast Name

Cell Number*

Area CodePhone Number

Additional Number

Area CodePhone Number

E-mail*

Parent/Guardian Father Information

Name*

First NameLast Name

Cell Number*

Area CodePhone Number

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the camper prescribed an inhaler? If yes, please explain any instructions.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Little Apple Circus Summer Camp during the selected camp. In exchange for the acceptance of said child’s candidacy by Little Apple Circus Summer Camp, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Little Apple Circus Summer Camp and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Little Apple Circus Summer Camp, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Little Apple Circus Summer Camp and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

EARLY BIRD REGISTRATION ENDS April 17th 2023

Last Chance Early Bird Discount Ends May17th, 2023

PLEASE SEND APPROPRIATE AMOUNT CHECK & ATTN TO:

LITTLE APPLE CIRCUS CAMP

731 McCall Rd

Manhattan, KS 66502

Check must be recieved by discount ending date

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*

Little Apple Circus Summer Camp Registration