Girls Growing Safely Summer Camp Registration Form!

Summer Camp Registration

Girls age 12-16 join us for our 3 day safety summer camp to learn how to be safe. Students will focus on internet safety, learn self defense skills, become CPR certified, experience real life safety simulations and focus on Mental Health. Students must register to attend and must attend June 25, June 26 and June 27, from 11:00am-3:00pm. Catered lunch will be provided!
Student's Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
1213141516
SmallMediumLargeXL2X3X
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Email
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Girls Growing II Women during the selected camp. In exchange for the acceptance of said child’s candidacy by Girls Growing II Women, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Girls Growing II Women. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Girls Growing II Women. including all staff, volunteers, board members and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is also granted to the Girls Growing II Women and its affiliates including Directors, staff and volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
YesNo
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Should be Empty:

Summer Camp Registration

Student's Information

Informed Consent and Acknowledgement

Medical Release and Authorization