(HEALTH EDUCATION AND RELATIONSHIP TRAINING SERVICES)

Youth Health & Registration Form for HEARTS Camp
(HEALTH EDUCATION AND RELATIONSHIP TRAINING SERVICES)
This form should be completed for each young person participating in HEARTS Camp. The gathered information is confidential and will be treated accordingly. It is requested in order to assist facilitators in providing the best possible experience for youth attending the camp. Please fill out details of medication fully (names of medication, dosages, inhalers etc

REFERRED BY : Live Achieve Believe Inc
Camp Date

MonthDayYear
Date
Camp Location
(If this date or location does not work for you, please call 727-258-7707 for additional dates/locations) SECTIONS A, B, and C are about the young person. SECTION D is about the parent/guardian.
FIRST NAME
2 STREET
CITY
STATE
YEAR IN SCHOOL (Please circle):
3 YEAR IN SCHOOL (Please circle)
DATE OF BIRTH

MonthDayYear
Date
SHIRT SIZE
AS
AM
MALE
FEMALE
DETAILS OF ANY REGULAR MEDICATION (IF NONE WRITE N/A)
DETAILS OF ANY ILLNESS WE NEED TO KNOW ABOUT (EG DIABETES, ASTHMA) (IF NONE
DETAILS OF ANY ILLNESS WE NEED TO KNOW ABOUT (EG DIABETES, ASTHMA) (IF NONE N/A)
DETAILS OF ALLERGIES (IF NONE WRITE N/A)
9 DETAILS OF ALLERGIES (IF NONE WRITE N/A)
DETAILS OF DIETARY REQUIREMENTS (IF NONE WRITE N/A)
11 DETAILS OF DIETARY REQUIREMENTS (IF NONE WRITE N/A)
SECTION C - YOUNG PERSON AGREEMENT

I agree that at HEARTS Camp I will:

1. Respect other camp participants. 2. Respect facilitators and leaders. 3. Respect the property. 4. Respect myself (e.g. won't be under the influence of illegal drugs/alcohol, or use tobacco or vape
SIGNATURE
13 DATE

MonthDayYear
Date
SECTION D - PARENT / GUARDIAN

PARENT/GUARDIAN
MIDDLE INITIAL
STREET
CITY
STATE
17 RELATIONSHIP TO YOUTH
DAYTIME PHONE

Area CodePhone Number
FEMALE
EVENING PHONE

Area CodePhone Number
MALE
MOBILE NUMBER

Area CodePhone Number
19 EMAIL ADDRESS
example@example.com
Safety
We will seek to ensure that young people in our care are nurtured and cared for in a safe environment and are protected from any potential harm. Strategies, policies and procedures are in place to ensure the physical, and psychological well-being of young people within our care. Facilitators are aware of policies, have been background checks and taken curriculum training.

Participation Consent I grant permission for my child to participate in two consecutive Saturday HEARTS Camps. Photo Media Release / Social Media I grant permission for photographs / video to be taken during youth group to be used for church/agency publicity purposes.

My youth is attending HEARTS Camp voluntarily and no undue pressure was applied to my family for his/her enrollment.
SIGNATURE
DATE

MonthDayYear
Date
(Please email -kathysmith@leadsflorida.org, - or mail completed registration form to

our office at 535 Central Avenue Ste. 409, St. Petersburg, FL 33701 or return to organization where received For questions or additional information, please call
Should be Empty:

(HEALTH EDUCATION AND RELATIONSHIP TRAINING SERVICES)

SECTION D - PARENT / GUARDIAN

MIDDLE INITIAL

STREET

FEMALE