School Break Action Camp Detailed Registration Form

School Break Action Camp Registration
Camper Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age
Gender*

MaleFemaleNonbinary
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Primary*
Secondary
E-mail*
example@example.com
Emergency Information - Primary
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Emergency Information - Secondary
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Pick-Up Policy: For the safety of all our campers, each person will be required to show a photo I.D. when they pick up their camper. Your cooperation is greatly appreciated as the Camp Director will not always be available to check out campers. In addition to the primary and secondary contacts, I authorize the following people to pick up the above-named child:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Particpation Waiver

Please read carefully and sign below. I understand that Afrim’s Sports assumes no responsibility for injuries or illnesses which my child may sustain as a result if his/her physical condition or resulting from his/her participation in any athletic activities, sports program, the use of any equipment, exercise or other activities. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illness which may result from his/her participation in these activities and I hereby release Afrim’s Sports, its agents, servants, and employees from any and all claims of injury, illness, death, loss or damage which he/she may suffer as a result of his/her participation in these activities and I recognize that Afrim’s Sports will make every reasonable effort to minimize exposure to known risks associated with the program. I understand that Afrim’s Sports is not responsible for personal property lost or stolen while members and/or program participants are using the Afrim’s Sports facilities on Afrim’s Sports premises. I give permission to Afrim’s Sports to use, without limitation or obligation, photographs, film footage, my child’s image/voice as well as my own for purpose of promoting or interpreting Afrim’s Sports programs. I acknowledge the Waiver as set forth.
Date*

MonthDayYear
Date
Name

First NameLast Name
Signature*

Clear
Sunscreen Permission

I give Afrim's Sports Action Camp counselors permission to apply sunblock, as needed, if I haven't done so prior to the start of camp. I understand that if I am unable to provide this sunblock, I agree to allow Afrim's Sports Action Camp counselors to apply the sunblock they have to use on my child.
Check one box to acknowledge that you have read and understand our Sunscreen Permission policy.*

I give Afrim's Sports Action Camp counselors permission to apply the sunscreen that they provide.I give Afrim's Sports Action Camp counselors permission to apply the sunscreen that I will provide from home.
Illness

In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian is unable to be reached, the child’s emergency contact will be notified. It is the responsibility of the parents or guardians to arrange for the child to be picked up from the facility as soon as possible. In the case that your camper or anyone in the immediate household of the camper develops a reportable communicable disease as defined by the State Board of Health, it is the responsibility of the parent to notify Afrim’s Sports within 24 hours or the next business day for Afrim’s to take proper action, except in the case of life threatening diseases which must be reported immediately.
Date*

MonthDayYear
Date
Name

First NameLast Name
Signature*

Clear
Emergency Authorization

Please read carefully and sign below. My signature authorizes the management and staff of Afrim’s Sports to act for me according to their best judgment in the event of a medical emergency and/or routine medical care. By my signature I hereby waive, release and hold harmless Afrim’s Sports, it’s management, volunteers, agents, and staff from any and all liability for any injuries, death, or illness sustained and/or incurred while at Camp and/or while using any facilities of, or participating in any of the activities or Afrim’s Sports. I/we grant permission for emergency medical treatment and/or routine medical care by the Afrim’s Sports camp staff, an ambulance, or private physician and/or hospital or emergency health care staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of my child and will be reported to me/us as soon as possible. My signature waives and/or releases Afrim’s Sports from any and all liability and/or financial responsibility for any medical expenses incurred.
Date*

MonthDayYear
Date
Name

First NameLast Name
Signature*

Clear
Waiver of Liability

The signature below signifies acceptance of the following waiver of liability. I acknowledge that Afrim Sports Inc. may compile address labels and lists and may utilize photographs of the named individual. I consent to these uses of my name, address and likeness and hereby waive all rights to compensation for their use in the promotion and/or operation of Afrim Sports Inc.
To induce Afrim Sports Inc. to accept registration and permit participation in Afrim Sports Inc. sports programs, I hereby give my consent and agree to release, indemnify and hold harmless Afrim Sports Inc., its officers, officials, coaches, employees and representatives from any claim arising out of injury to the named individual. I also hold harmless Afrim Sports Inc., its officers, officials, coaches, employees and representatives from and against any claim arising out of injuries or conditions caused by or aggravated by my refusal to obtain available medical treatment based on religious or philosophical beliefs or otherwise.
I understand that as a participant in Afrim Sports Inc. sporting events that I must abide by all rules, regulations and philosophies of Afrim Sports Inc.
Date*

MonthDayYear
Date
Name

First NameLast Name
Signature*

Clear
Health Report and Comments on Child’s Development

(This form needs to be accompanied by immunization records from your physician’s office.)
Has your child been diagnosed with any of the following:*

ADDADHDODDOCDPTSDANXIETYDEVELOPMENTAL DELAYLANGUAGE DELAYAUTISM SPECTRUM DISORDERBIPOLAR DISORDERCEREBRAL PALSYDOWN'S SYNDROMEDEPRESSIONTOURETTE'SFRAGILE XNoneOther
Check any or all that may apply:*

Chronic/severe Health Condition (Asthma, Diabetes, etc.) Additional forms required.Does your child have an Individual Education Program? (IEP)Does your child have a Behavior Management Plan?None
Please list and describe any allergies, special medical or physical conditions or problems that Afrim’s should be aware of, including chronic health problems:
List instructions to be taken in the event of an emergency allergic reaction:
List any special medications for chronic problems and/or restrictions for child’s care below:
In emergencies requiring medical attention, your child will be taken to the nearest hospital emergency room. Your signature below authorizes a representative of Afrim’s Sports to have your child transported to the hospital.
Medication

Only prescription medication or over the counter medication with permission from child’s physician will be self-administered by your child. Do not send medications with your camper. Medicine must be handed to the Camp Director or Head Coach at check-in by the parent. All medicines must be kept by the staff in the locked cabinet. Children are not permitted to keep medications in their book bags or pockets. PRESCRIPTION MEDICATIONS SHOULD BE IN THE ORIGINAL CONTAINER AND LABELED WITH THE CHILD’S NAME, INSTRUCTIONS, INCLUDING TIMES AND AMOUNTS FOR THE DOSAGES, WITH AN ORIGINAL PHARMACY LABEL ONLY.
Date*

MonthDayYear
Date
Signature*

Clear
Immunization Records

Cancelof
Should be Empty:

School Break Action Camp Registration

Camper Information

Health Report and Comments on Child’s Development

In emergencies requiring medical attention, your child will be taken to the nearest hospital emergency room. Your signature below authorizes a representative of Afrim’s Sports to have your child transported to the hospital.