Trenton Summer Camp Registration - Ages 12+
Information of Parent/Guardian
Parent/Guardian Name
*
Parent First Name
Parent Last Name
Acct Record Type
Contact Record Type Participant
Household Name
Contact Record Type General
Full Name Parent
Parent/Guardian Gender
*
Male
Female
Nonbinary
Choose not to respond
Relationship to Participant
*
Phone Number
*
Please enter a phone number.
Parent Email Address
*
example@example.com
Home Address
*
Street Address & Apt
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Ward
North
South
East
West
Language Spoken at Home
*
English
Spanish
Other
Emergency Contact
Other than Parent/Guardian
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship to Participant
*
Emergency Contact Phone Number
*
Please enter a phone number.
Emergency Contact Email Address
*
example@example.com
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For County Reporting purposes only
Are you head of household?
Yes
No
Are you 62 years of age or older
Yes
No
Are you disabled?
Yes
No
Race
Black/African American
Black/African American & White
Asian
Asian & White
Native Hawaiian/Pacific Islander
American Indian
American Indian & White
American Indian & Black/African American
White
Other Multi-Racial
Ethnicity
Hispanic Ethnicity
Not Hispanic Ethnicity
Household Size
Type a number between 2 and 8
Annual Household Income (for Funding Purposes only)
$26,100 or less
$26,101-$43,500
$43,501-$62,800
Above $62,801
Annual Household Income (for Funding Purposes only)
$29,350 or less
$29,351-$48,950
$48,951-$70,650
Above $70,651
Annual Household Income (for Funding Purposes only)
$32,600 or less
$31,601-$ 54,350
$54,351-$78,500
Above $78,501
Annual Household Income (for Funding Purposes only)
$35,250 or less
$35,251 $58,700
$58,701-$84,800
Above $84,801
Annual Household Income (for Funding Purposes only)
$37,850 or less
$37,851-$63,050
$63,051-$91,100
Above $91,101
Annual Household Income (for Funding Purposes only)
$40,450 or less
$40,451-$67,400
$67,401-$97,350
Above $97,351
Annual Household Income (for Funding Purposes only)
$44,120 or less
$44,121-$71,750
$71,750-$103K
Above $103K
Household Income
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Participant Registration
Name1
*
First Name1
Last Name1
Birth Date
*
-
Month
-
Day
Year
Date
Which Session(s) do you want to attend?
*
Summer Session I - July 7th - July 18th
Summer Session II - July 21st - August 1st
Summer Session III - August 4th - August 15th
Last Date of Year
-
Month
-
Day
Year
Date
Are you disabled?
*
Yes
No
Age1
Program1
Closing
Program2
Program3
Race
*
Black/African American
Black/African American & White
Asian
Asian & White
Native Hawaiian/Pacific Islander
American Indian
American Indian & White
American Indian & Black/African American
White
Other Multi-Racial
Ethnicity
*
Hispanic Ethnicity
Not Hispanic Ethnicity
Current Month
-
Month
-
Day
Year
Date
Current Month2
Summer or Not
Gender
*
Female
Male
Nonbinary
Choose not to respond
Participant Cell Phone
Please enter a phone number.
Participant Email
example@example.com
School Name
*
Injuries/Illnesses/Medical Conditions/Current Medication
*
Accommodations Necessary for Participation
*
Please list any of the following: Medication allergies, food allergies, dietary restrictions or chronic health concerns.
Does Participant Have Health Insurance
Yes
No
Do you wish to register more participants?
*
Yes
No
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Additional Participant2
Name2
First Name2
Last Name2
Birth Date2
-
Month
-
Day
Year
Date
Age2
Participant Type2
Are you disabled?
Yes
No
Gender
Female
Male
Nonbinary
Choose not to respond
Race
Black/African American
Black/African American & White
Asian
Asian & White
Native Hawaiian/Pacific Islander
American Indian
American Indian & White
American Indian & Black/African American
White
Other Multi-Racial
Ethnicity
Hispanic Ethnicity
Not Hispanic Ethnicity
Participant Cell Phone
Please enter a valid phone number.
Participant Email
example@example.com
School Name
Injuries/Illnesses/Medical Conditions/Current Medication
Accommodations Necessary for Participation
Please list any of the following: Medication allergies, food allergies, dietary restrictions or chronic health concerns.
Does Participant Have Health Insurance?
Yes
No
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Permissions and Waivers
I hereby give permission for TCS staff to administer first aid as needed
In the event of an emergency when parent, guardian, and emergency contact cannot be reached, I hereby give permission to the medical personnel selected by TCS to administer emergency care.
I give permission for the image and voice of the participant to be used by the Trenton Circus Squad in any media for publicity.
I give permission for the participant to travel by car with the Trenton Circus Squad staff.
I give permission for the participant to leave Trenton Circus Squad unaccompanied.
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