2023 PB and J Participant Registration

Make sure read this entire document before proceeding.

Campers Name*

First NameLast Name

Parent email*

example@example.com

Home phone number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell phone number*

Area CodePhone Number

*

MaleFemale

Date of Birth*

Current School*

Highest Grade Completed (by start of camp)*

Age of camper on June 27, 2023*

Adult T-Shirt Size*

Cancellation Policy

Should you choose to withdraw your application for camp, please refer to this refund policy.

Cancel before May 27, 2023 - 100% Refund

Cancel before June 10, 2023 - 50% Refund

Cancel after June 10, 2023 - NO REFUND

All requests for cancellation must be sent by email to

info@pbandjleadership.org

Signature acknowledging cancellation policy*

Clear

Name*

First NameLast Name

Parent(s) Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Emergency Contact (if parents cannot be reached)*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Physician Name*

First NameLast Name

Physician Phone Number*

Area CodePhone Number

Medical Payment Responsibility*

InsuranceIndividual

Insurance Company and Policy Number (if none type none)*

Food allergies (if none type none)*

Special Health Concerns (if none type none)*

Drug Allergies (if none type none)*

Asthma*

YesNo

Inhaler*

YesNo

ALL Current Prescription Medications (if none, type none)*

NOTE: If participant is taking prescription medication regularly, please bring a supply in the original prescription bottle in the name of the participant. This will be turned over to medical staff for dispensing and kept in the medical station. It is the responsibility of the participant to go to the medical station to take his/her medication as directed by the prescription.

Medical Procedure Acknowledgement*

Clear

Waiver of Claim/Media and Medical Release

NOTE: All attachements within this form will be sent to your email after submission for your further review.

Parent Name*

First NameLast Name

Parent Signature and Claim/Media and Medical Release Form*

Clear

Date

Participant Name*

First NameLast Name

Participant Signature*

Clear

Date

PB and J Participant Registration

Medical Permission Form

Waiver of Claim/Media and Medical Release

Additional Information

Camp Payment

Enter coupon