Youth Summer Groups Registration Form

Youth Summer Groups Registration Form
Please select the programs:

Remarkable Readers Club (Ages 6-12 Co-ed) June 3rd / 9am – 2pm"BROTALK" (Ages 12-17 Adolescent Males ) June 3rd / 3pm – 5pmSenior Year Productions (2025-2026 High School Seniors) July 9th / 5pm – 7pmCreative Arts Therapy Group (Ages 13–18) June 2nd-July 24th 2:30-4:30 pmRadiant Girl empowerment group( ages 9-12) June 10th- July 15th
STUDENT AND PRIMARY CONTACT INFORMATION
Student Information*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age (at the time of Camp):*
Name of School*
Grade*
Please list the grade the student just completed
Name of Parent/Guardian/Primary Contact:*

First NameLast Name
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Preferred contact method:*

Mobile PhoneHome PhoneWork PhoneEmail
What is the race/ethnicity of your student?*

WhiteBlackAsianAmerican Indian/Native AlaskanNative Hawaiian/Pacific IslanderOtherPrefer Not to Say
Does your child have insurance*

YesNo
Name of Health Insurance Provider:
Policy Number:
Policy Holder Name :
Policy Holder DOB :
Please note: Providing insurance information does not guarantee coverage for summer group services. Hamilton Counseling will make every effort to notify you once authorization is received from your insurance provider.
Medical Release Information

The purpose of this section is to ensure that medical personnel have details of any medical problem that may interfere with or alter treatment.
Primary Care Physician:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Preference:*
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).*
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?*

YesNo
If yes, explain:*
Is your child allergic to any type of food or medication?*

YesNo
If yes, explain:*
Does your child require a special diet?*

YesNo
If yes, explain:*
Medical Emergency Contact/Alternate Pickup/Release:
Medical Emergency Contact (other than parent/guardian): *
Authorized for Pickup: *
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my child is injured or becomes ill.*

YesNo
Initials*
I understand that Hamilton Counseling and Consulting, PLLC will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.*

YesNo
Initials*
SAFETY INFORMATION

(Please list all known conditions so we can accommodate your student’s needs.)
Does your student have any medical conditions, allergies, or special needs the staff should know about?*

YesNo
Please list below*
Does your student have any behavioral or emotional issues the staff should know about?*

YesNo
Please list below*
Is your student taking any medications to treat these conditions?*

YesNo
Please list below*
Academic Status
Does your student have a current 504/IEP in place (if answered yes, please provide a copy of the mostcurrent IEP / Accommodations)?*

YesNoUnsure (would like more information)
Please list the academic areas and challenges that your student currently faces.
Terms of Agreement

Photo ReleaseI hereby give permission for my child to be photographed during the Hamilton Counseling and Consulting, PLLC. I understand the photos will be used to keep a journal of activities, to share during PowerPoint presentations and/or reports to our donors, and for promotional purposes, including flyers, brochures, newspapers, and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation, and all photos are the property of Hamilton Counseling and Consulting, PLLC.
Parent’s/Guardian’s Initials:*
Signature
Date*

MonthDayYear
Date

My Products

Remarkable Readers Club Registration

$125.00 Quantity

Other Group Programs

$75.00 Quantity

Total

$0.00

Credit Card

No Refund Policy Statements for Summer Group Registration

Please note that all summer group registration fees are non-refundable. We appreciate your understanding, as this policy aligns with standard practices for seasonal programs.
Should be Empty:

Youth Summer Groups Registration Form

STUDENT AND PRIMARY CONTACT INFORMATION

Medical Release Information

Medical Emergency Contact/Alternate Pickup/Release:

SAFETY INFORMATION

Academic Status

Terms of Agreement

Credit Card