Winter Break Camp 2022 Registration Form

Winter Break Camp Registration

December 19th-23rd & 26th-30th
Camper Information
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
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.*
If none, please just say no.
Is the camper prescribed an inhaler or insulin? If yes, please explain any instructions.
Insurance Provider*
Insurance Policy Number*
Select your camp week

December 26th - 29th Ages 5-14January 2nd - 5th Ages 5-14
Waiver of Liability and Media Release
Waiver Liability

YES-I agree to signing the waiver of liabilityNO-I do NOT agree to signing the waiver of liability
Waiver Liabiltiy Signature

Clear
Media Release*

Yes, I grant TRAK permission to take and use photos of my child.No, permission to take or use photos denied.
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.
Should be Empty:

Winter Break Camp Registration