2022 Summer Registration

COMMUNITY BUILDING INSTITUTE CHAMPIONS OF MIDDLETOWN'S FAMILIES

CBI Middletown Summer Program Registration

Camper's Full Name

Parent/Legal Guardian Name

Male

Female

Is this your first CBI Camp?

Preferred Camp Location

Rosa Parks (K-5) RSHCC (K-5) Mayfield (K-5) Smith Park (K-5) Highview 6th Grade Center (6th Grade Only)

Adult T Shirt Size

Current School Grade in August 2022

Camper's School

Date of Birth

Date

Address

Home Phone

Work Phone

Cell Phone

Emergency Contact Information: In case of an emergency and the parent/guardian cannot be contacted please list 2 additional emergency contacts.

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Physician

Phone

Preferred Hospital

Please List All Individuals Authorized to Pick Up Your Child

Allergies or Medical Concerns

Medical Release and Release of Liability:

I authorize the staff and volunteers of the RISE Academy to provide basic first aid or to call additional medical care on my child's behalf in the event of an emergency if I cannot be reached or when delay would be dangerous to my child's health. I further agree to release the CBI & City of Middletown staff and volunteers from any liability connected with my child's participation in the 2021 summer

Iauthorize the CBI & City of Middletown staff members to take photographs and / or videos of my

child while participating in the Fire & Leadership Camp programs. I understand that CBI & the City of Middletown may use these photographs and videos for internal and external purposes including (but not limited to) press releases, websites, social media and publications.

Text Alerts: I understand that by signing this form I will receive text alerts pertaining to CBI Middletown Programs. If I would like to opt out of these alerts I will check the box at the bottom of the page.

I hereby waive, release, absolve, indemnify, and agree to hold harmless CBI Middletown, Inc. its directors, officers, organizers, sponsors, supervisory staff, participants and any other affiliates, and the City of Middletown for, from, and against all liability because of any bodily injury, or property damage, known or unknown, which may occur or result from the participation of my child(ren) in any and all activities whether the result of negligence or for any other cause. I individually and as a parent/guardian for my child, have read this release and understood all the terms. I execute it voluntarily and with full knowledge of its significance.

Parent/Guardian Signature

Clear

Date

Expect a call from the RISE ASP staff to touch base on opportunities for parent/guardian involvement and confirmation of form submission.

Please mark here if you do NOT wish to receive text alerts from CBI Middletown Inc.