Autism Winter Camp Registration Form

Camp Ausome Winter Break Registration

This form must be completed for each child registered. If the child is older than 11 when camp starts they cannot be registered. Children must be at least 6 at the time of registration. Physicals are required to participate in camp.
Camper Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade entering fall 2024*
Gender*

MaleFemale
T-shirt size*

Small youthMedium youthLarge youthAdult smallAdult medium
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent 1 Name*

First NameLast Name
Parent 2 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
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Pick-up Information
Photo identification is required to be presented by person authorized to pick-up your child. NO CHILD will be released to any unauthorized person or anyone who fails to provide a photo ID.
Authorized Pick-up Person*
Authorized Pick-up Phone Number*
Authorized Pick-up Person*
Authorized Pick-up Phone Number*
Medical Providers
Medical Doctor*
Doctor's Phone Number*
Please enter a valid phone number.
Dentist*
Dentist's Phone Number*
Please enter a valid phone number.
Allergy Doctor*
Allery Doctor's Phone Number*
Please enter a valid phone number.
How did you hear about us?*
Tell us how you hear about us.
Do you give permission for your child to be photographed?*
Do you give permission for your child's photograph to be used for promotional purposes by Freddie Ford Family Foundation?*
Will your child need any special support or assistance?*
If your child needs any special support or assistance, please describe.*
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is the child prescribed an inhaler? If yes, please explain any instructions.*
Is your child able to use the bathroom independently? Please note for your child's safety they must be able to independently use the bathroom.*
We will have snacks available such as goldfish, pretzels, chips, Popsicles and fruit snacks. Do you give your child permission to eat a snack provided by Camp?*
Does your child have any behaviors that we need to be aware of?*
Does your child have any self injurious concerns that we need to be aware of?*
Do you have any safety concerns that we need to be aware of (does your child elope or wander)?*
What are your child's likes?*
What are your child's dislikes?*
What are some strategies that work to support your child if he/she gets upset or overstimulated?*
What are some strategies to avoid when your child is overwhelmed or upset?*
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Freddie Ford Family Foundation during the selected camp. In exchange for the acceptance of said child’s enrollment in camp by Freddie Ford Family Foundation, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Freddie Ford Family Foundation. and all its respective officers, agents, and representatives 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 hereby waive all claims against Freddie Ford Family Foundation. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball, soccer etc. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Signature*

Clear
Medical Release and Authorization As Parent 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 the Freddie Ford Family Foundation and its affiliates including Directors, Coaches, and volunteers 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 session. 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.
Signature*

Clear
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.

I ACKNOWLEDGE AND UNDERSTAND THAT CAMP AUSOME IS EXEMPT FROM LICENSURE BY THE MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION.
Signature*

Clear

Camp Registration Fee*

Camp Registration FeeRegistration fee for Camp Ausome 1/2/25 - 1/3/25

$80.00 Quantity

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Camp Ausome Winter Break Registration