Youth Coding Camp 2024

Child's Information

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does your child need transportation?

YesNo

Which summer camp will the child attend?

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

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 child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the Child 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 Children 1st Community Development Services(Children 1st) during the selected coding workshop. In exchange for the acceptance of said child’s candidacy by Children 1st ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Children 1st 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 Children 1st . including all staff, volunteers 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, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Photo Use Release Authorization As Parent and/or Guardian, herby grant and authorize Children 1st Community Development Services the right to take, edit, alter, copy, exhibit, publish, distrubute, and make use if any an all pictures or video taken of the child listed above, by Children 1st Community Development Services to be used in and/or for legelly promotional materials materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, funderaising letters, annual reports, press kits, and submissions to journalists, websites, social networking sites, and otherprint and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or hereafter devised. This authorization shall coninute indefinitely it is otherwise revoked in writing by the person signing this acknowledgment. I understand and agree that these materials shall become propety of Children 1st Community Development Services and will not be returned. I hereby hold harmless, and release Children 1st Community Development Services from all liabilty, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate. I hereby certify that I am the parent or guardian of the above named child. I do hereby give my consent with reservation to the forgoing on behalf of this individual.

Medical Release and Authorization As Parent and/or Guardian of the named child, 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 child. 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 Children 1st and its affiliates including Directors and Staff 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 workshop. 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.

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.