Kelly Academy Summer Camp Registration Form

Summer Camp Registration-6/3-7/22, 2024
Camper Name
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Camper's Information
Address*
City*
State*
Zip*
Home Phone*

Area CodePhone Number
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Birth Date*

MonthDayYear
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Email Confirmation
Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)
Other Information
Health Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration please see the health officer at that time. Please bring all medication in ORGIANAL CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that campers name and the correct dosage.
Is camper free from infectious desease or conditions?*

YesNo
Are immunications up to date?*

YesNo
Date of last tetanus shot*
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
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 any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
List all medications, both prescribed and over the counter, all medications will be turned into the Leader except rescue inhalers, bring all medication in original containers.*
Payment Information

$65 Registration Fee Due
Payment Metods:

* Cash

* Paypal:@kellyacademy

* Venmo: @JenniferMKelly

*Cashapp:@29229k

*Debit/Credit card
If paying through a platform, You can pay multiple registration fees with one transaction. In memo, please put the camper(s) name. If you have any questions feel free to contact Jennifer Kelly at 803-470-4265 or Alexander Blair 803-716-4272
Camper Release
Camper Release (List anyone, including parents, to whom your camper can be released)*
- Be certain to enter your email address correctly on the registration form to receive confirmation via email.
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, 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 camper by authorized personnel. The camp carries secondary insurance. I understand that the above named camper 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 camp and participate in all activites. I authorize Kelly Academy to use my camper's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the camp.

My initials also agree that I am aware that while at Kelly Academy my child will be in a building that has cameras and is subject to be on at any moment. By signing, I also release all responsibility of Kelly Academy and Mary L. jacobs Life Center incase of an accident or injury that may take place while at camp.
Signature*

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Summer Camp Registration-6/3-7/22, 2024

Camper Name

Camper's Information

Parent or Legal Guardian Information

Email Confirmation

Other Information

Health Information

Payment Information

Camper Release