Program Registration

Parent/Guardian Information
Caregiver 1 *

First Name Last Name
Caregiver 1 Cell Number *
Caregiver 1 Email *
Caregiver 2 (if applicable)

First Name Last Name
Caregiver 2 Cell Number
Caregiver 2 Email
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Number
Emergency Information
Emergency Contact Name *

First Name Last Name
Relationship *
to child
Phone Number *
Alt. Phone Number
Does your youth have any allergies, chronic illness, or medical conditions such as pregnancy, diabetes, etc? If yes, please describe. *
Does your youth use any medications? Please list medications and instructions for administration. *
I understand that medications must come in the original prescription bottles with the correct dosing on the label. *

Yes Not applicable No
NOTE: Please be prepared to review the medications and prescriptions with the staff if needed.
Healthcare Provider Name, Office, and Phone Number:
Denali Kid Care #:
PERMISSION TO ADMINISTER OVER-THE COUNTER MEDICATIONS

Sun block

Insect repellant

Lip balm

Rash ointment

Tylenol

Ibuprofen

Antiseptic ointment

Band aids

Anti-itch cream

Cough syrup

Cough drops

Decongestant

Antihistamine

Antacid

Pepto Bismol
I hereby give the Staff permission to administer the above over-the-counter products according to manufacturer’s instructions, or as otherwise specified. *

Yes No
Youth's History
Why do you feel your youth is a good fit for a trauma-informed camp? *
Can you give us a list of behavior(s) your youth often displays? *
Does your youth have any diagnoses? *
e.g: ADHD, FASD, PTSD, TBI
To your knowledge, what is your youth's trauma history--what is their story? *

Contact Community Development Director, Jessica Jones at 907-717-9485 or jessica@reach907ak.org for more details.
Informed Consent and Acknowledgement

I hereby give my approval for my youth’s participation in any and all activities during the selected camp. In exchange for the acceptance of said youth’s candidacy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless REACH 907, Royal Family KIDS, INC (RFK), TeenReach Adventure Camp (TRAC), and all its respective officers, agents, and representatives from any and all liability for injuries to said youth arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said youth, I hereby waive all claims against REACH 907, RFK, and TRAC, including all affiliates, 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 camp activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named child(ren), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child(ren), 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(lives), 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 athlete. 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 REACH 907 and its affiliates including Directors and Staff to provide the needed emergency treatment prior to the youth’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

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(ren), in my absence.

During camp, prescription medication will be administered to youth as directed by a physician. REACH 907 will do everything in its power to prevent incorrect medicine from being given. However, the local REACH 907, RFK, and TRAC, are not liable for incorrect medicine provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medication, bottles, and dosages at the time of registration. This is not the time to give medication vacations to your youth.
Text & Email *
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM COMMITTING TO A REACH 907 PROGRAM FOR A CHILD IN MY CARE.

I ACKNOWLEDGE THAT REACH 907 IS A FAITH-BASED ORGANIZATION OPERATING A FAITH-BASED CAMP PROGRAM.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AND BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Caregiver or Legal Guardian's E-Signature *
Social Worker or Legal Guardian E-Signature
(OCS will receive a copy of this form and will provide the social worker's or legal guardian's signature)
Should be Empty:

REACH 907 Program Registration

Parent/Guardian Information

Emergency Information

Youth's History

Requirements