Youth Summer Groups Registration Form
Please select the programs:
Remarkable Readers Club (Ages 6-12 Co-ed) June 3rd / 9am – 2pm
Remarkable Minds ADHD Parent Group (All ages Co-ed) July 10th 6pm – 7:30pm
"BROTALK" (Ages 12-17 Adolescent Males ) June 3rd / 3pm – 5pm
Senior Year Productions (2024-2025 High School Seniors) July 9th / 6pm – 7:30pm
STUDENT AND PRIMARY CONTACT INFORMATION
Student Information
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
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 Name
Last Name
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
*
example@example.com
Preferred contact method:
*
Mobile Phone
Home Phone
Work Phone
Email
What is the race/ethnicity of your student?
*
White
Black
Asian
American Indian/Native Alaskan
Native Hawaiian/Pacific Islander
Other
Prefer Not to Say
Does your child have insurance
*
Yes
No
Name of Health Insurance Provider:
Policy Number:
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.
Primary Care Physician Address:
Street Address
Street Address Line 2
City
State / 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?
*
Yes
No
If yes, explain:
*
Is your child allergic to any type of food or medication?
*
Yes
No
If yes, explain:
*
Does your child require a special diet?
*
Yes
No
If yes, explain:
*
Medical Emergency Contact/Alternate Pickup/Release:
Medical Emergency Contact /Alternate Pickup/Release:
*
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.
*
Yes
No
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.
*
Yes
No
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?
*
Yes
No
Please list below
*
Does your student have any behavioral or emotional issues the staff should know about?
*
Yes
No
Please list below
*
Is your student taking any medications to treat these conditions?
*
Yes
No
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)?
*
Yes
No
Unsure (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
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: