ECNC 2022 Winter Camp

East Cleveland Neighborhood Center 2022 Winter Camp
Complete an enrollment form for each child. If Enrolling more than one child from the same family/household complete a separate form for each child.

If you have any questions contact

Mrs. Shalonda Swanson,

Administrative Assistant at

216-932-3626 or sswanson@ec-nc.org
Children Information
Date*

MonthDay Year
Date
Name*

First Name Last Name
Birth Date:*

MonthDay Year
Date
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender Identity: Preferred pronouns:*
Child's Race/Ethnicity (check all that apply)*
What school does your child attend? *

Superior Elementary, East Cleveland, OhioCaledonia Elementary, East Cleveland, OhioMayfair Elementary, East Cleveland, OhioKirk Middle School, East Cleveland, Ohio
Does your child have any allergies or health conditions of which we should be made aware of? If yes, what?*
Is there anything else you would like to share about your child?*
Name of person completing this form*

First Name Last Name
Relationship to child(ren)*
Phone Number*

Area Code Phone Number
Email Address:*
example@example.com
Emergency Contact Information
Emergency Contact Name:*

First Name Last Name
Phone Number*

Area Code Phone Number
Email Address:*
example@example.com
Is this person authorized to pick up the child(ren) you enrolled in this program? *

YesNoN/A
Please list the Name, Relationship, and Phone Number of an adult authorized to pick up the child(ren)? *
In case of an emergency, I give permission for any of the above individuals to be contacted and my child(ren) may be released to any of them.
Media Release
Please select Yes or No to permit East Cleveland Neighborhood Center to use your child’s image, photograph, video, likeness, voice, and statements for program promotion and publication purposes in any type of media including print, video, radio, television, and internet.

YesNo
Field Trip
Please select Yes or No to permit East Cleveland Neighborhood Center to take your child off of the premises during the winter camp.

YesNo
Type a question

Type option 1Type option 2Type option 3Type option 4
Informed Consent: I hereby give approval for my child’s participation in this event. I understand all risks incidental to the conduct of this program/event/activity and release, absolve and hold harmless East Cleveland Neighborhood Center and all its respective offices, agents and representatives from any and all liability for injuries to the said child arising from participation in this event/program/activity. Medical Authorization: In the event reasonable attempts to contact me have been unsuccessful, I hereby authorize provision of emergency treatment if my child becomes ill or injured while participating in this event/program/activity, including, if necessary, transfer of child to local hospital or health care facility.*

Clear
Should be Empty:

East Cleveland Neighborhood Center 2022 Winter Camp

Children Information

Emergency Contact Information

Media Release

Field Trip