Shake-A-Leg Miami - Marine Academy 2023

Shake-A-Leg Miami - Marine Academy Summer Camp 2023 June 12th- August 4, 2023

Summer Camp Enrollment Form
Camper Information
Camper's Name*

First NameLast Name
Camper's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camper's Phone Number*

Area CodePhone Number
Camper's Email*
example@example.com
Camper's Birthdate*

MonthDayYear
Date
Last Four Digits of Camper's Social Security Number*
Camper's Gender*

MaleFemale
Camper's Ethnicity*

Hispanic or Latino or Spanish OriginNot Hispanic or Latino or Spanish Origin.
Camper's Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMultiracial
Is the Camper Proficient in English?*

YesNo
Other Language(s) Spoken in Camper's Home (Check any that apply)*

SpanishHaitian Creole
Camper's Current School*
Camper's Current Grade*
Camper's Shirt Size*
Camper's Shoe Size*
Does the Camper Receive Any of the Following Assistance? (Check all that apply)

McKay ScholarshipSNAPGovernment
Parent/Guardian Information
1st Parent/Guardian Name*

First NameLast Name
1st Parent/Guardian Phone Number*

Area CodePhone Number
1st Parent/Guardian Email*
example@example.com
2nd Parent/Guardian Name

First NameLast Name
2nd Parent/Guardian Phone Number

Area CodePhone Number
2nd Parent/Guardian Email
example@example.com
Emergency Contact Information
Emergency Contact Name (Non-Parent/Guardian)*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Adults Authorized to Pick Up the Camper
If you would like to authorize any non-parent adult to pick up the Camper from camp, please provide their information.
1st Authorized Adult Name

First NameLast Name
1st Authorized Adult Phone Number

Area CodePhone Number
2nd Authorized Adult Name

First NameLast Name
2nd Authorized Adult Phone Number

Area CodePhone Number
3rd Authorized Adult Name

First NameLast Name
3rd Authorized Adult Phone Number

Area CodePhone Number
Bus Information
Bus Selection*

Bus 1 - Charles R. Drew Elementary - 1775 NW 60th Street, Miami, FL 33142 (Pick Up: 8:15 AM, Drop Off: 3:30 PM)Bus 2 - Irving & Beatrice Peskoe K-8 Center - 29035 SW 144th Avenue, Homestead, FL 33033 (Pick Up: 7:00 AM, Drop Off: 2:30 PM)Bus 3 - Historic Lyric Theater 819 NW 2nd Ave Miami, FL 33136No Bus - Parent, Guardian or Authorized Adult will Drop Off and Pick Up Camper at SALM
Camper's Medical Information
Does the Camper have health insurance? (ex. private insurance, KidCare, Medicaid)*

YesNo
Is the Camper prone to Startle Reflex or Seizures?*

YesNo
Does the Camper have any Allergies?*

YesNo
If Yes, please list all of the Camper's Allergies
Does the Camper take any Medications regularly?*

YesNo
If Yes, please list all of the Camper's medications
Does the Camper have a Disability or Special Need?*

YesNo
If Yes, the Camper has... (Check any that apply)

A 504 PlanAn Individualized Education Plan (IEP) from the School SystemA medical diagnosisA diagnosis from a certified/licensed professional (i.e. Psychologist)Disclosure by Parent or Guardian describing the Camper's specific condition and/or need for accommodations
If Yes, Check any options below that describe the Camper's Disability or Special Need

Autism Spectrum DisorderChronic Medical ConditionDevelopmental DelayEmotional and/or Behavioral DisorderHearing Impairment (or Deaf)Visual ImpairmentIntellectual DisabilityLearning DisabilityPhysical DisabilitySpeech/Language Disability
What are the main ways in which the Camper communicates (Check all that apply)

Speaks and is easily understoodSpeaks but is difficult to understandUses communication devices like pictures or a boardUses sign languageUses gestures or expressions like pointing, pulling, etc.Uses sounds that are not words like laughing, crying, etc.
Areas in which the Camper needs assistance (Check any that apply)

Academic, learning, reading activitiesAdapting to activities taking into account visual or hearing impairmentHolding a crayon/pencil, writing, using scissors or other fine motor tasksManaging feelings and/or behaviorPersonal services like help with feeding, using the toilet, or changing clothesSports or physical activities like running or other gross motor tasksUsing adaptive device(s) like a wheelchair, crutches, brace, or walker
List any Accommodations needed
Please upload the Camper's IEP (if applicable)

Browse Files

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Please upload any additional supporting documentation for the Camper (if applicable)

Browse Files

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Description Code or Additional Notes
Please let us know any notes or additional information we should know about the Camper
Statements
In consideration of Shake-A-Leg Miami, Inc. (“SALM”) extending to me the opportunity to participate in SALM’s Summer Camp I fully assume all risks that might arise, both known or unknown, and both inherent to the program or activity in which I am engaging and any risks that are not inherent, and waive all liability for all such risks, including without limitation any potential liability that SALM may have for its own negligence or the negligence of any of its agents, officers, directors, or employees, in connection with my participation in the program or activity, and in particular, without limitation, to the extent permitted by law, I and my heirs, representatives, executors, or administrators and my undersigned parent, guardian or aide (if applicable) remise, release, indemnify, acquit and hold harmless and forever discharge SALM and its directors, officers, employees, agents, instructors, volunteers, rescue and support personnel, from any and all claims and liability, including without limitation liability for SALM’s and its directors’, officers’, employees’, agents’, instructors’, volunteers’, rescue and support personnel own negligence, and all obligations, damages, claims, causes of action, judgements, costs and charges which I may suffer or which may be incurred by me for any reason of any occurrence during my travel to and from the activity or program, and during my participation therein, whether resulting from any acts, omissions or negligence or from acts of God or nature. I also agree to assume liability for all and any damages to SALM property that is under my control while participating in any SALM activity. During my participation, I hereby agree to comply with all SALM rules and regulations, applicable county and municipal ordinances, and with the laws of the State of Florida and the United States.*

I have read and agree with the above terms.
I hereby give my full and unconditional permission to SALM for the free use of my and the Camper's name, likeness, and image (including without limitation permission to use any photo and video in which I may appear) in any present or future media story, promotion, advertisement, or account of an SALM related program, event, or activity, including without limitation in connection with any present or future public relations or fundraising event or activity.*

YesNo
Click here to download the Medical Authorization Documents
It is my responsibility to submit a Medical Authorization Document, which can be downloaded using the link above.*

I agree with the above statement
I understand I will need to provide the registered nurse with a prescription from the doctor for any medications that need to be administered by the nurse during camp hours.*

I agree with the above statement
Email
example@example.com
Should be Empty:

Shake-A-Leg Miami - Marine Academy Summer Camp 2023 June 12th- August 4, 2023