New Albany Kindergarten Academy
Camper's Information
Camper's Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Parent Name
*
First Name
Last Name
Parent Phone #
*
-
Area Code
Phone Number
Parent Name
First Name
Last Name
Parent Phone #
-
Area Code
Phone Number
Parent/Guardian Information
The parents/guardian listed below will be the authorized person to pick-up the child after the camp.
The parents/guardian listed below will also be the primary emergency contact person.
Name
*
First Name
Last Name
Relation
*
Phone Number
*
-
Area Code
Phone Number
Medical Information
Does the child have any allergies? If yes, please list them below:
Does the child have any current medical conditions? If yes, please list them below:
Does the child takes any medication? If yes, please list them below and explain its purpose:
Authorization
I, the parent/guardian of this camper gives New Albany School District authority to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached. I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
I released the organizers, coaches, staff, or managers of New Albany School District for any responsibility in case of accident, illness, or injury during Kindergarten Academy.
Parent/Guardian Signature
*
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Submit
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