Youth Power Summer Camp Registration Form
These forms are required for your children to attend camp.
Please fill in the date in which the camper will start camp:
CAMP WEEKLY FEE: $30
Camper's Information
Camper Name
*
Nickname
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Camp Transportation:
Bus Pick up/Drop off
Parent Drop off/pick up
Camper Swimming Ability
*
Non-Swimmer
Beginner Swimmer (can swim on front 20ft without flotation)
Advanced Swimmer (can pass swim test)
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Youth Power Permissions
I give permission for photography for publicity purposes. I give permission for my child to be transported by authorized personnel.
Signature
Parents' Information
Parent/Guardian
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Work Information
*
Or enter N/A if not applicable
Employer Phone
Format: (000) 000-0000.
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where would you like to be reached while your child is at camp?
*
Cell Phone
Work Phone
Home Phone
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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. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child
*
Emergency Contact #2
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child
*
Authorized Pickup: Name, Relationship, and Phone Number
*
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Medical / Health Information
Name of Physician or Clinic/Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Attach immunization record or waiver
Upload a File
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Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please list and explain any allergies
*
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
*
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?
*
Yes
No
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
0/150
If yes, does this medication, food supplement, or medical food need to be administered at the day camp?
*
Yes
No
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
*
Yes
No
Please explain
*
0/150
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
*
Yes
No
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
*
0/200
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions.
*
0/200
Additional Medication
Check all that apply
Prescription medication
Nonprescription medication
Refrigeration required
Topical product or lotion
Food supplement
Modified diet
Name of medication
Exact dosage
To be administered at the following times
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CAMP RELEASE/WAIVER FOR YOUTH POWER SUMMER CAMP (MINORS)
Name of Minor:
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: