Kreative Success Academy

Summer Camp Application Student Information

Student Name

Age

School

Last 4

Address

Street Address Line 2

Zip

School

Student ID

1st Parent Guardian

Place of Work

Phone

Cell Phone

2nd Parent Guardian

Place of Work

Cell Phone

Phone

Emergency Contact

Emergency Contact: Telephone: Phone

Cell

Relationship

Name and phone number(s) of person(s) allowed to pick up your child:

2

Phone

3

Phone

4

Phone

5

Phone

Any special instructions, such as custody or restraining orders must be attached to this application and discussed.

Please list any other information youd like to include about your camper

Please print all information clearly

Name of camper

Kreative Success Academy does not discriminate based on race, color, sex, handicap, religion, or national origin. Kreative Success Academy reserves the right at its sole discretion to refuse an application or dismiss a child from camp. No refund will be made of fees if the child has attended any portion of the camping period.

ParentGuardians Signature

I give Kreative Success Academy permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at The Peoples Channel and can be used for promotional purposes without notification.

ParentGuardians Signature

I give permission for Kreative Success Academy to transport my child off camp property for the purpose of field trips and/or medical care. I understand that a schedule of events will be available to me and that all events are subject to change due to weather and/or scheduling conflicts without notice.

ParentGuardians Signature

I authorize the camp staff to act as the agent of the parents in any emergency situation or to administer basic first aid for the health and welfare of the camper involved. I am responsible for the expenses involved if the services of a physician or hospital are required. Please request a waiver for persons requesting exemption from medical treatment.

ParentGuardians Signature

Hospital preferred

By signing below, I agree to adhere to all the Policies and Procedures set for by Kreative Success Academy:

ParentGuardians Signature

Please print all information clearly The medical background of each camper is required as part of the camp's registration process. The camp director must be advised in writing of any condition that would limit the camper's ability to participate in any program.

Childs Name

Date of Birth

Date

Child's Pediatrician Name

Phone number

Date of last physical

Date

Medical conditions

List of past medical treatments

List all current medications regardless of whether it needs to be taken a camp or not

Will your child need to take any prescription medications while at camp? Yes/No If yes, please request a medical dispensing form. Return the form and medication in a Ziplock bag with your child's name on it on the first day that they attend camp. Allergies: (Please put N/A if your child does not have an allergy)

Food

Medication

Insect

Other

Does your child require an Epipen

If yes, you must provide the camp with an Epi-pen to be kept at camp during your child's enrollment. Epi-pen must be accompanied by a current prescription and a doctor's note. Specific Activities to be restricted for health reasons:

Specific Activities to be restricted for health reasons

ParentGuardians Signature