Clone of Day Camp Registration Form

Camp Registration Form

These forms are required for your children to attend camp.
Camper's Information
Camper Name*
Nickname
Date of Birth*

MonthDayYear
Age
NOTE - Children need to have completed Kindergarten before they are eligible to participate in camp.
Entering Grade in 2021/22*
Which Master Minds session would you like your child to attend?*
T-Shirt Size
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.

Parents' Information

Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
Relationship to Child*
E-mail*
Cell Phone*
Home Phone*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name*
Or enter N/A if not applicable
Parent's Work/School Phone
Parent's Work/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where would you like to be reached while your child is at camp?*

Cell PhoneWork PhoneHome Phone
Parent/Guardian 2
Parent/Guardian 2*

First NameLast Name
Relationship to Child*
E-mail*
Cell Phone*
Home Phone*
Home Address Same as Parent/Guardian 1?

Yes
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name*
Or enter N/A if not applicable
Parent's Work/School Phone*
Parent's Work/School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where would parent/guardian 2 like to be reached while your child is at camp?

Cell PhoneWork PhoneHome Phone

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Emergency Contact #1
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Secondary Phone Number*
Relationship to Child*
Emergency Contact #2
Type a question
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Secondary Phone Number*
Relationship to Child*

Statement of Understanding
Authorization and Acknowledgment: By signing this waiver and consent, I, the legal parent/guardian grant permission for myself/my children to participate in any and all activities including but not limited to trampoline time, nature walks behind the fence, water activities such as sprinklers and kiddie pools. I recognize and acknowledge the inherent risks that these activities may present for me/my children.

I authorize The Center to release my demographic information to supporting supporting staff. Because I acknowledge the risks of attending allowing my children to participate, I agree to release and hold harmless Master Minds Kids Camp and its founder, trustees, directors, officers, employees, agents, affiliates, volunteers and medical staff (“Staff”) from any and all injury claims of any other nature which may result from my/my children’s participation at and travel to or from The Center. I agree to indemnify and hold The Center, its Staff and other children at The Center harmless from any and all liability caused by myself/my children, whether or not intentional.

Medical Consent: The Center will make every effort to contact me in the case of an emergency. I give my permission for The Center and its medical staff to administer any medications needed and to provide and arrange for any necessary medical treatment to my children while at Master Minds Kids Camp, including onsite and offsite emergency care. I accept responsibility for the costs of all such medical treatment.

Photography Release: In consideration of my children’s participation at Master Minds Kids Camp and without any further consideration from Master Minds Kids Camp, I hereby grant permission to staff and affiliates to utilize my appearance, performance or voice in any and all manner and media throughout the world for the purpose of promotion, reporting or publication. The Center may use my/my children’s name, likeness, voice and biographical material in connection with publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photograph.

Please contact the Office of Camper Recruitment at 385-238-8749 before signing if you have questions.
I have read this form carefully and have had all questions answered before signing this legal document and giving the consents and waivers contained in it. I acknowledge that this is a legal document and I will be bound by my agreement to its terms. I represent to Master Minds Kids Camp that all information provided in the medical form is accurate and complete and that I have the legal authority to provide consent on behalf of my child.
Child’s Name (Print)*
Parent/Guardian’s Name (Print)*
Parent/Guardian must sign, signature represents legal authority for my child listed above.*
Date Signed*

MonthDayYear
Camp Director Name and Contact Info
Should be Empty:

Camp Registration Form

Camper's Information

Parents' Information

Emergency Contacts/Authorized Pickup

Medical / Health Information

Additional Medication

Statement of Understanding