Holly Springs CARE Program Student Information 2022-2023

CARE Program Student Information
Student's Information
Student's Full Name *

First Name Middle Name Last Name
Student's Date of Birth *

Month Day Year
Date
Student's Grade Level for School Year 2022-2023 *
What school does the student attend? *
Student's Gender *

Male Female
Student's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Parent/Guardian Contact Information
Primary Parent/Guardian's Full Name *

First Name Last Name
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail Address
Secondary Parent/Guardian Contact Information
Secondary Parent/Guardian's Full Name

First Name Last Name
Primary Phone Number

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email Address
example@example.com
Emergency Contact
Emergency Contact's Full Name *

First Name Last Name
Relationship to Student *
Emergency Contact's Primary Phone Number *

Area Code Phone Number
Emergency Contact's Secondary Phone Number

Area Code Phone Number
CARE Program Information Information
Pictures or videos of your child may be taken while participating in Town activities and may be used by the Town for program publicity. These images and videos may be used, but not limited to, in the HURRAHS Program Book, the Summer Camp Book, the Parks and Recreation Facebook page, the Town website, or Town social media.

If you do not want your student photographed or filmed, please email Rachel Porter at rachel.porter@hollyspringsnc.gov The Town will make reasonable efforts to avoid access to, or remove, any images or recordings of the opted out camper.
Food Permission (When Applicable): Often food items are brought in for snacks, treats, and instructional activities. Please select one of the following: *

My child has permission to participate in food activities under the direction of program staff. My child may not participate in food activities.
Field Trip Permission (When Applicable). Please select one of the following: *

My child has permission to participate in any field trips that leave the Hunt Recreation Center, Bass Lake Park, or the Holly Springs Cultural Center with the supervision of program staff. This permission is good for the entire program. My child may not participate in any field trips.
Reasonable Modification Request
Programs and camps are provided for people with all abilities. If you or your child needs a reasonable modification, please select YES below and complete the registration at least two (2) weeks prior to the start of the program/camp. Each request will be assessed in compliance with ADA. *

Yes Not Applicable
Health Information
Is student up to date on all immunizations? *

Yes No N/A
Does your child have any allergies? *

No Yes- Food Allergies Yes- Medication Allergies Yes- Environmental Allergies
If student has allergies, please list and explain. If none, please type N/A. *
Please list any significant medical history (surgeries, injuries, serious illness, etc.). If none, please type N/A. *
Please list any on-going medical conditions (asthma, seizures, headaches, etc.). If none, please type N/A. *
Please list any medications that student is currently taking. If none, please type N/A. *
What medications are required to be administered while the student is in the supervision of CARE staff (Additional medical forms will be required)? If none, please type N/A. *
Student's Primary Physician (if student does not have a primary care physician, please write N/A) *
Physician's Phone Number

Area Code Phone Number
Student's Dentist (if student does not have a dentist, please write N/A) *
Dentist's Phone Number

Area Code Phone Number
Hospital Preference *
Is there any other information that staff should know in order for your child to have a successful experience? If none, please type N/A. *
Authorization for Pick Up
Please list any other individuals that may pick up your children from the program. Include name, relationship to child, and telephone number. If none, please type N/A. *
By signing here, I agree that I have read and discussed with my child the guidelines and expectations as outlined in the Hunt Center CARE Operations Plan and the Hunt Center CARE Manual. *

Clear
Date *

Month Day Year
Date
Should be Empty:

CARE Program Student Information

Student's Information

Primary Parent/Guardian Contact Information

Secondary Parent/Guardian Contact Information

Emergency Contact

CARE Program Information Information

Reasonable Modification Request

Health Information

Authorization for Pick Up