Camp Emily Registration

Camp Emily Registration
October 9th, 2021 | 9 am to 3 pm
Children age 7-18

Please complete the following online registration and submit by October 1st, 2021.
Limited Space is available.

Name of person completing this registration?*

First NameLast Name

What is your relationship to the child/children?*

Parent or GuardianYou have permission from the Parent/Guardian to complete this formYou do not have permission from the Parent/Guardian.

PLEASE NOTE: Sorry, but you must either be the Parent or Guardian of the child/children or have the permission of the Parent or Guardian to complete this form.

Please garner the permission of the Parent or Guardian to complete this form and then return to this form to complete it. Thank you.

1st Child's Name

First NameLast Name

Please list this childs gender/age/grade level

2nd Child's Name

First NameLast Name

Please list this childs gender/age/grade level

3rd Child's Name

First NameLast Name

Please list this childs gender/age/grade level

Parent's/Guardian's Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent's/Guardian's Home/Cell Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Parent's/Guardian's Email Address

example@example.com

Will there be another adult attending?

YesNo

Additional Attendee Name

First NameLast Name

Additional Attendee's relationship to children?

Additional Attendee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Additional Attendee's Home/Cell Phone

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

Additional Attendee's Email Address

example@example.com

Name of the person who died?

First NameLast Name

Date of the death?

Date

Cause of death?

Relationship to child(ren)

Served by Hospice

YesNo

If yes, which hospice?

Is there another death associated?

YesNo

Name of the person who died?

First NameLast Name

Date of the death?

Date

Cause of death?

Relationship to child(ren)

Served by Hospice

YesNo

If yes, which hospice?

How did you hear about Camp Emily?

Any special dietary requirements for persons attending?

Other issues/concerns we should know about?

*You will be receiving a phone call from a Camp Emily team member to confirm your registration.

Camp Emily will not discriminate because of race, color, creed, religion, national origin, sex, sexual orientation, marital status, status with regard to public assistance, membership or activity in a local human rights commission, disability, age, or other legally protected characteristics.

Please verify that you are human*