2023-24 MEYERS CAMP REGISTRATION

MEYERS CAMP REGISTRATION FORM

For all Boys & Girls attending school in Alameda (Grades K to 5th) Camp Times: 8:00 a.m. to 4:00 p.m. daily 1724 Santa Clara Ave. • Alameda, CA • 94501 • (510) 521-1743
Before proceeding with registration please read through Meyers Camp procedures:

• Once you have completed and submitted your registration(s), you will receive your email confirmation within 1-3 business days confirming your child's enrollment. If camp is full, you will be placed on the wait list and be contacted. The confirmation email will include details regarding fees and payment due dates. (Please don’t send your payment until you have received your Meyers camp confirmation email)
• If camp fees are not paid within two business days of receiving your invoice, your child’s spot will be released.
• In the unlikely event enrollment is below our threshold on a particular day, we reserve the right to cancel Meyers Camp programming. If this is the case, you will receive at least one week’s notice of camp cancellation and will be fully refunded.
• Any changes to previously registered days, including cancellations or transfer of days, must be made 5 business days in advance of Last Day of Registration for the camp session and in writing. Only 1/2 of the daily rate may be refunded upon proper cancellations.
*

I have read and understand Meyers Camp procedures:
Parent/guardian Signature*

Clear
Date*

MonthDayYear
Date

PARENT/GUARDIAN RELEASES

You are only required to fill out this info the first time you register your child during the 2023-2024 school year or unless there are changes.
Liability Agreement Release - Required for Participation

I hereby authorize, as parent or legal guardian, for my child to participate in Girls Inc. Programs. In consideration for this participation, I do hereby, for myself and my heirs and assigns, release and agree to indemnify and hold harmless Girls Inc. of the Island City, its employees and volunteers from all liability, loss, claim, demand, action or cause of action which arises or may arise or be occasioned in any way by such participation. I also release and hold harmless Girls Inc. of the Island City, its employees and volunteers from all liability, loss or claim which may occur in transporting my child for the purposes of participating in any Girls Inc. activities.
Parent/Guardian signature*

Clear
Date*

MonthDayYear
Date

Media/Photo Release (optional)

I hereby authorize Girl Inc. of the Island City, its agents and others working for it or on its behalf to use my child’s image/likeness/voice/artwork/writing in still photos, slides video productions, radio coverage, television coverage, interviews, testimonials and/or any other media purposes, including Girls Inc. website, for promoting and representing Girls Inc. and its programs, and do hereby grant and convey unto Girls Inc. all rights, title, and interest in the above media including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
Do you agree to media release?*

YesNo
Parent/Guardian signature*

Clear
Date*

MonthDayYear
Date

HEALTH INFORMATION

You are only required to fill out this info the first time you register your child during the 2023-2024 school year or unless there are changes.
PLEASE PRINT ALL OF THE INFORMATION BELOW
Child's Information*

First NameLast Name
Birthdate*

DayMonthYear
Date
Age*
Age
Special Medical Limitations
Food Allergies:
Medicine Allergies:
Other Allergies:
Please List ALL medications (including OTC) taken by your child:
Special Disabilities:*

LearningDevelopmentalEmotionalVisualHearingMobilityNone/UnknownOther Special Needs
Parent/Guardian - Please read and sign: I give my permission to obtain all emergency medical or dental care prescribed by a duly licensed Physician (M.D.) Osteopath (D.O) or Dentist (D.D. S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Medical Insurance Name*
Medical Insurance Coverage Number*
Physician Name
Physician's Phone Number
Dentist's Phone Number
Dentist Name

EMERGENCY CONTACT INFORMATION
PLEASE PRINT ALL OF THE INFORMATION BELOW:

Child’s Last NameFirst Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In addition to the parents/guardians, the following adults (18 years and older) are authorized to take this child from the facility. These names will also serve as emergency contacts. These contacts must be reachable and available for immediate pick-up or response.
Emergency Contact 1
Emergency Contact name
Phone Number
Please enter a valid phone number.
Emergency Contact 2
Emergency Contact name
Phone Number
Please enter a valid phone number.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Based on court documents on file at site, my child should NEVER be released to:
Type the name of the person(s)

	YES	NO
Currently attending AIK?
Currently Attending Girls Program?
New to Meyers Camp?

MEYERS CAMP REGISTRATION FORM