School Registration

School Registration
Institution Name
Please bring to The Center the following documentation to secure your child(ren) spot at Pre-K Boot Camp

• Original Certified Birth Certificate

The birth certificate will be used to confirm your childs age ONLY.

You will also be required to complete the ASQ-3 (Ages and Stages Questionare) before camp and after camp. This is a requirement of our grant funding.
Student Information
Name *

First Name Last Name
Birth Date *

Month Day Year
Gender *
Ethnicity *
Address *

Street Address

City State / Province

Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone Number *

Area Code Phone Number
Email Address *
Emergency Contact #1
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Is this contact authorized to pick up child? *

Yes No
Emergency Contact #2
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Is this contact authorized to pick up child? *

Yes No
Physician and Medical Information & Consent
Preferred Hospital *
Insurance/Health Coverage (Company) *
Food Allergies (If none, type none) *
Health Conditions (If none, type none) *
Current Medications (If none, type none) *
Medication Allergies (If none, type none) *
MEDICAL CONSENT & AUTHORIZATIONS

Authorization to Provide Emergency Care

I understand that every reasonable effort will be made to contact me at the contact information I have provided in the event of an emergency.
If I cannot be reached at the contact information supplied, I hereby give permission to the physician selected by The Center, Iasis Christian Center, and/or the Academy of Excellence , to hospitalize, secure treatment for, and to order injection, anesthesia, or surgery for my child as named herein until I arrive. I give permission for the release of the Health and Information Form as well as any accompanying information or medical records to medical
professionals in the event of injury or illness. I hereby certify that the information I have provided in the registration is complete and accurate.

Authorization for Administration of Medication

I give permission for any prescription medications brought to camp by my child to be administered by the camps program director who will administer the medication according to the directions on the pharmaceutical container, unless otherwise directed by a physician. Additionally, Iunderstand that all medications (prescription and non-prescription) brought by my child to camp will be turned over to and stored by thecamps program director
Signature *

Clear

Waiver of Liability and Authorization to Participate
I accept full responsibility for myself or my child in the case of bodily injury, death, loss of personal property, and expenses thereof and I hereby
waive any claims or demands which I or any member of my family may have against Presbyterian Camp and Conference Ministries of SW Florida,
Inc., its employees, volunteers, officers, or directors, that may result from negligence by Presbyterian Camp and Conference Ministries of SW
Florida, Inc., its employees, volunteers, officers, or directors. If there is any question regarding my child’s ability to participate in these activities, I
will inform camp staff prior to allowing my child to participate. I understand that my child is required to follow established rules and procedures
associated with each activity. I acknowledge the nature of the activities and the fact that not all the stresses and hazards connected with the
activities can be foreseen. I recognize that there is a significant element of risk in any adventure, sport, or activity associated with the outdoors.
Knowing that there are inherent risks, dangers, and rigors involved in the activities, I permit my child to participate in the activities of this camp.

Media Release

Occasionally, photos and video footage is taken during The Centers camp and used for promotional material. I authorize ICC to use photos taken of my child for use in brochures, articles, websites, and/or videos.
Signature *

Clear
Notes
Should be Empty: