Camp Wannado Registration Form Step 2

Email

example@example.com

Desired Program

When will your child start?

Location

Child Last Name

Child First Name

Teacher Name

School Name

Date of Birth

Date

GR

Child Last Name

Child First Name

Teacher Name

School Name

Date of Birth

Date

GR

Child Last Name

Child First Name

Teacher Name

School Name

Date of Birth

Date

GR

Last Name

First Name

Cell Phone

Work

OTHER

Address

DL#

State

License Expiration

Last Name

First Name

Cell Phone

Work

OTHER

Address

DL#

State

License Expiration

Name

Relationship

Phone #

Name

Relationship

Phone #

Name

Relationship

Phone #

Name

Relationship

Phone #

Password

PICK UP LISTCHILD(REN)'S FULL NAME

SCHOOL CHILD(REN) ATTEND:

Health Insurance Co. Name

Policy #

My child has permission to be transported by Camp Wannado After School Program Inc on field trips and/or for after school pick up.

YesNo

Date of Last Physical Exam

Date

Do you carry Medical/Hospital Insurance?

YesNo

Check and give appropriate dates when applicable.

Give appropriate dates for the health history check marks above. (If applicable)

Allergies (check all that apply)

PenicillinInsect stingsPoison IvyHay Fever

Food Allergies (list foods)

Other (please describe)

Immunization Record required if child is not registered in a Broward County Public School or Miami-Dade County Public Schools

Broward County School / Miami-Dade Public School

Immunization Records Provided

Operations of Serious Injuries

Dietary Restrictions

Upon immediate need for medical attention for your child, the undersigned gives consent to any x-ray examination, anesthetics, medical or surgical diagnosis or treatment, and hospital care to be rendered to (child’s name) upon the advice of a physician and/or surgeon licensed under the provisions of the Medical Practice Act.
Camp Wannado After School Program Inc will not be held responsible for any medical expenses due to an emergency.
The undersigned further authorized Camp Wannado After School Program Inc to have (child’s name) released into the custody of its representative, should hospital care no longer be required.
The undersigned further authorizes Camp Wannado After School Program Inc staff and/or director to perform CPR/First Aid on (child’s name) in the event of an emergency.

Medical Authorization for:

Childs Name

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Summer Camp Registration Form

Child Information

Child Information

Child Information

Primary Parent

Secondary Parent

Authorize Pick Up list

Password

Insurance

Release of Liability

Medial Release Form

Health History

Medical Information

Hospital Insurance