Hero Academy Registration Form

Hero Academy Registration
Little Hero's Information
Last Name*
First Name*
Middle Name*
Gender*

MaleFemaleOther
Address*
City*
State*
Zip*
Birth Date*

Month Day Year
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area Code Phone Number
Cell Phone

Area Code Phone Number
Parent /Legal Guardian 2*
Relation 2*
Work Phone 2*

Area Code Phone Number
Cell Phone 2

Area Code Phone Number
Home Phone*

Area Code Phone Number
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area Code Phone Number
Emergency Number #2*

Area Code Phone Number
Hero Buddy

List first and second choice, not all requests are guaranteed.
Hero Buddy #1
Hero Buddy #2
Email Confirmation
Parents Email (Hero's confirmation will be sent by email, if left blank it will be mailed)
- Be certain to enter your email address correctly on the registration form to receive confirmation via email.
Other Information
How did you hear about the Hero Academy?
First Time Hero?*

YesNo
Health Information

Certified Safety Team on site at all times.
Are immunizations up to date?

YesNo
Date of last tetanus shot
Any activity the camper should be restricted from?
Any physical, mental or other condition that would require special attention or medication while at camp?
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.
List any allergies (ex: bees,peanuts, dairy)
Any dietary needs that we should know about?
Hero Photo Release
I agree that photos of my child can be taken on used on United Community Empowerment social media platforms.

YesNo
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named child, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named child by authorized personnel. The camp carries secondary insurance. I understand that the above named child will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend UCE Hero Academy and participate in all activites.
Electronic signature, please initials*