Winter Break Camp 2022 Registration Form

Winter Break Camp Registration

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

First Name Last Name
Birth Date*

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Information
Name*

First Name Last Name
Home Number

Area Code Phone Number
Cell Number*

Area Code Phone Number
E-mail*
Emergency Information
Emergency Contact's Name*

First Name Last Name
Relationship
Phone Number*

Area Code Phone Number
Alt. Phone Number

Area Code Phone 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 19th-23rd Ages 8-14December 26th-30th Ages 5-12
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