Summer Camp Detailed Registration Form

Camper Information

Child's Name*

First NameLast Name

Birth Date*

MonthDayYear

Age*

Grade*

Gender*

MaleFemaleOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Home Number

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number*

Please provide answers to the questions below. Use No or N/A for questions that do not apply.

Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is your child prescribed an inhaler? If yes, please explain any instructions.*

Why do you feel your child would benefit from Executive Function Camp?*

Does your child currently have a mental health diagnosis? If yes, please provide details.*

Will your child need any special accommodations or support during camp?*

Please describe your child's strengths.*

Is there any additional information you would like to share about your child?

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Katie Greenleaf, MA, LPCC of Anchored Unbound Counseling Coaching and Consulting during the selected camp session. My enrolling my child in executive function camp, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Katie Greenleaf, MA, LPCC, Anchored Unbound, and affiliated representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Katie Greenleaf, MA, LPCC and Anchored Unbound, including owners and lessors of premises used to conduct the event.

Medical Release and Authorization As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further injury. Permission is hereby granted to the attending physician to proceed with any necessary medical intervention, x-ray examination and immunizations for the named child. In the event of an emergency, 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 Katie Greenleaf, MA, LPCC of Anchored Unbound, and any affiliates, to provide the needed emergency treatment prior to the child’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 the named minor child, in my absence.

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.

Signature*

My Products*

2022 Play & Learn Executive Function Camp 8-11 year olds Product Image

2022 Play & Learn Executive Function Camp 8-11 year oldsAugust 1-4 9am-Noon

$675.00

2022 Fun & Function Executive Function Camp 9-12 year olds Product Image

2022 Fun & Function Executive Function Camp 9-12 year oldsAugust 8-11 9am - Noon

$675.00

Total

$0.00

IMPORTANT PLEASE READ: The cost of registration is not refundable in any circumstance. While we realize things do come up that may cause your child to be unable to participate after registering, we are not able to refund monies due to the cost of materials and requirements surrounding the submission of invoices to insurance companies. In the event your child is unable to participate, we will provide you with a credit that you can use for any available service at Anchored Unbound. This credit will not expire.

By signing below, you are acknowledging that you are aware of and accept this policy.

If you need a detailed invoice to submit to your insurance company for reimbursement, please email info@anchoredunbound.com and we will provide you with one.

If you have any questions, please call our office at 419-271-7797

Signature*

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Summer Camp Registration