AHS Summer Camp Form

1. CAMPER’S INFORMATION HERE
Camper Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age at time of camp
Grade entering this fall
The Camps you are interested in (check all that apply):
List all Allergies and Dietary Restrictions
2. Parent/Guardian 1 Information:

(all correspondence and invoices will be sent to this person)
Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Occupation
Email Address
please be sure that your email address is valid. You will receive all correspondence to this email. Add “info@averroesinstitute.com” to your address book to ensure delivery.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Camper
Custodial Parent
3. Parent/Guardian 2 Information:

(all correspondence and invoices will be sent to this person)
Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Occupation
Email Address
please be sure that your email address is valid. You will receive all correspondence to this email. Add “lmurphy@livingstonisd.com” to your address book to ensure delivery.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Camper
Custodial Parent
4. Emergency Contacts and Authorized Pick Up Persons

(In addition to parents/guardians) Use this area to list the individual(s) we may contact in an emergency and/or you authorize to pick up your camper from
Name 1

First NameLast Name
Relation to Camper
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell/Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Name 2

First NameLast Name
Relation to camper
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell/Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
5. How did you hear about AHS Summer Camp?
6. PARENTAL CONSENT TO TREATMENT / ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

I hereby authorize the Averroes high School Directors to provide routine health care, administer medications as ordered by a physician, obtain emergency medical treatment including radiology and laboratory studies, and arrangement of transportation for same. I agree to the release of any records necessary for medical treatment or insurance purposes. I consent to allow the physician selected by Averroes high school Directors to secure and administer treatment, including hospitalization for the minor named above.
Parent Signature
Print Name
I understand these risks and release Averroes High School, and the directors, trustees, officers, volunteers and employees of Averroes High School, from all liability for damages or injuries resulting from activity, negligence or defects in the preparation, instruction, or equipment.

Averroes High School is not responsible for lost, stolen, or damaged personal articles.

I individually and corporately agree to hold harmless, Averroes High School, its volunteers, agents, employees and officers irrespective of any negligent act or omission by Averroes High School and/or those individuals arising from or related in any way to this Averroes High School Summer Camp Program.
Parent Signature
Print Name
7. PAYMENT INFORMATION
Number of camp weeks
$400 per child
Type of Payment
Signature of Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

1. CAMPER’S INFORMATION HERE

2. Parent/Guardian 1 Information:

3. Parent/Guardian 2 Information:

4. Emergency Contacts and Authorized Pick Up Persons

7. PAYMENT INFORMATION