The Huddle Youth Center

The Huddle Youth Center

Camp Junnebug Registration & Permission Form
Dear Parent/Guardian,Thank you for taking the time to register your child to participate in The Huddle Youth Center summer program provided by JUNNEBUG Foundation.
Student Information
Student's Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Parent/Guardian Email Address

Email AddressAlternate Email
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
List any allergies and medical conditions of child.
List T-Shirt Size
(Place a check mark to signify your understanding and agreement)
Consent For Medical Treatment:
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty: