Summer Camp Allergy and Emergency Contact Form 2024

Allergy and Emergency Contact Form Summer Camp 2024

Fill out the form carefully for registration
Camper's Information
Camper's Name*

First NameLast Name
Camper's Preferred Name (Nickname)
(Name that student prefers to go by if different than above)
Birth Date*

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any and all allergies staff should be aware of or put N/A if this does not apply to your child.*
Does your child require an EpiPen for any of the allergies listed above? Please put N/A if this does not apply to your child.*
First Parent Information

Please list the information of the parent that will be the main point of contact this summer!
First Parent's Name*
Please list the parent who will be the main point of contact.
First Parent's Email*
First Parent's Phone Number*
Relationship to Student*
Second Parent Information
Second Parent's Name*
Second Parent's Email*
Second Parent's Phone Number*
Relationship to Student*
Emergency Contact's Name*
Please list an emergency contact other than the parent's listed above.
Emergency Contact's Phone Number*
Preferred Hospital In Case of Emergency:*
Authorized Pick Up List:
Pick Up Password*
Please list a password below that will be used during pick up if your carpool sign is not available.
People on this Authorized Pick Up List must still show their vaild ID at pick up AND have either the pick up password or the carpool tag given on Monday Mornings.
Full Name:
Please list name as it is listed on driver's license
Phone Number
Full Name:
Please list name as it is listed on driver's license
Phone Number
Full Name:
Please list name as it is listed on driver's license
Phone Number
Photo Release
I give permission to The Cornwell Center staff to publist any photos or videos that may be taken of my child for Cornwell Center use.
Signature for Photo Release

Clear
Date

MonthDayYear
Date
Waiver
I understand that the Cornwell Center at Myers Park Baptist Church assumes no responsibility for injuries or illnesses which may be sustained as a result of participation in any athletic activities, sports programs, and the use of any equipment, exercise or other activities. I acknowledge that I assume the risk for any and all illness which may result from participation in these. In consideration of the privilege of participating at the Cornwell Center, I hereby voluntarily release and discharge the Cornwell Center at Myers Park Baptist Church and its agents, servants and employees from any and all claims for injury, illness, death, loss or damage which may be suffered as a result of participation in these acdtivities. A parent/responsbile party much discuss having a physician examine my child/me whitin a reasonable time prior to the start of the program/activity to determine my child/I am free of communicable disease and have not been exposed to such. I hereby give permission to the medical personnel selected by the Cornwell Center staff to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes and to provide or arrange necessary related transportation for me/my child in the event of medical emergency. I understand that no accident/medical insurance is provided with this activity.
Signature*

Clear
Date*

MonthDayYear
Date
Covid-19 Waiver
Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Myers Park Baptist Church in no way warrants that COVID-19 infection will not occur through accessing our facilities or being present on our campus.
Signature*

Clear
Date*

MonthDayYear
Date
Camp Rules:
1. All campers, regardless of age, MUST BE COMPLETELY POTTY-TRAINED PRIOR TO THE START OF THEIR CAMP. Campers need to be able to use the bathroom completely by themselves. If a camper has 2 consecutive accidents you will be asked to pick up your child and they will not be allowed to return to camp and a refund will NOT be given. No diapers, pull-ups, or travel potties are allowed.
2. Carpool Tags will be given on Monday morning at Camp Check In, Carpool Tags must be visible on the right side of your dashboard at pick-up. You must have our Carpool Tags or your password that you will create on your Allergy/Emergency Contact Form. Homemade tags will NOT be accepted.
3. You will be charged a dollar per minute per child late fee every minute after 12:45pm.
4. You must be fully registered with an active card on file to be added to a waitlist.
5. There is a one time nonrefundable $10 fee to join our waitlist to ensure you have an active account and credit card on file with us. Please make sure if you are no longer interested in a camp you email to remove your child from a waitlist because your child will be automatically placed in a camp that they are on the waitlist for and cancellation fees will apply.
6. Please make sure all items are labeled with your child's first and last name. We ask that all toys, electronics, and other non-camp essentials are left at home. The Cornwell Center is not responsible for any lost items.
7. Campers of all ages are asked to bring a change of clothes, water bottle, peanut free snack, and peanut free lunch.
8. For any cancellations, there will be a $75.00 cancellation fee per camp per space. Cancellations MUST be made at least two weeks prior to the start of camp or no refunds will be given. Cancellations must be submitted to summercamp@cornwellcenter.org. All Cancelations must be made prior to 9am on Monday two weeks before your camp starts.

Example: If your child starts camp Monday June

24th you must cancel prior to 9am on June 10th.

There are no exceptions on this rule.
I Parent's Name* have read, understand, and will follow these rules.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Allergy and Emergency Contact Form Summer Camp 2024

Camper's Information

First Parent Information

Second Parent Information

Authorized Pick Up List:

Photo Release

Waiver

Covid-19 Waiver

Camp Rules: