Glow & Grow Summer Camp Registration Form

Camp Registration
Camper Information

Camper information is kept confidential.
Camper's Name

First NameLast Name
Birth Date

MonthDayYear
Age
Grade Child Will Enter Next School Year
Gender

MaleFemaleNonbinary
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is English the child's primary language?

YesNo
*Does the child qualify for free or reduced lunch? (Answers provided for categories with an asterisk are voluntary and used to obtain grants and donations.)

YesNo
*Select the option that describes the child's home. (Answers provided for categories with an asterisk are voluntary and used to obtain grants and donations.)

Two parent householdOne parent householdLives with grandparentsLives with Aunt or UncleLives with Other Guardian/Caregiver
*Select the option that describes the child's race. (Answers provided for categories with an asterisk are voluntary and used to obtain grants and donations.)

African American/BlackAsian or Pacific IslanderHispanic or LatinoIndigenous or Alaska NativeWhite or CaucasianMultiracialNot Listed
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed any medication that needs to be administered during camp? If yes, please explain any instructions.
Informed Consent and Acknowledgement

By signing this registration form, I hereby give my approval for my child’s participation in any and all activities prepared by Blazing Brilliance LLC during the Grow & Glow Camp. In exchange for the acceptance of said child’s candidacy by Blazing Brilliance LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Blazing Brilliance LLC and all its respective officers, agents, and representatives, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, volunteers, and, if applicable, owners and lessors of premises used to conduct the Camp, 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 (and on behalf of my child) waive all claims against and forever release, discharge, and agree to hold harmless and indemnify Blazing Brilliance LLC and all its respective officers, agents, and representatives, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, volunteers, and, if applicable, owners and lessors of premises used to conduct the Camp from and against all loss, liability, claims, or harm occurring on, in, or on the premises rented, leased, or utilized by Blazing Brilliance for the camp, or in any way arising out of (a) attendance at or participation in the Activity and/or (b) use of any facility, service, or equipment provided by Blazing Brilliance LLC.
Photo, Video, & Feedback Consent and Acknowledgement

By signing this registration form, I grant permission to Blazing Brilliance LLC, its agents, its employees, & contracted staff irrevocable and unrestricted rights to my image, written feedback, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration for any lawful purpose, including publication, promotion, archive in any manner or any medium that exists now or in the future.
Medical Release and Authorization

By signing this registration form, as Parent, Caregiver, and/or Guardian of the named camper, 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 hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Blazing Brilliance LLC and its affiliates including directors, teachers, and assistants to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

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.
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
Signature

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Camp Registration

Camper Information