Youth Summer Camp 2025 Registration Form

Youth Summer Camp Registration Waiting List

June 2nd - July 10th, 2025 Ages: K - 6th
Camper Information
Camper Name*

First NameLast Name
Nickname
Shirt Size*
Birth Date

MonthDayYear
Age*
Grade 2025-2026 School Year*
Gender*

MaleFemale
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or More Races
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child attend the New Miami School District or reside in the Village of New Miami?*

School DistrictVillage of New MiamiOther
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
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
INFORMED CONSENT AND ACKNOWLEDGEMENT
Will your child be attending the New Miami Summer School Program?*

Yes (If yes, please answer the following question)No (Skip, following question)
In the event that I grant permission, One Village of New Miami is authorized to collect my child from the New Miami Schools Summer Program. It is worth noting that both the New Miami Summer School Program and One Village of New Miami Youth Camp will be held in the same building.

AgreeDisagree
I hereby give my approval for my child's participation in any and all activities prepared by One Village of New Miami during the youth summer camp. I waive all claims for damages arising from my child's participation in the youth summer camp. This release discharges One Village of New Miami, its officials, officers, volunteers, staff, and agents from liability for injuries to said child arising out of traveling to, participating in, or returning form selected camp sessions.*

AgreeDisagree
Medical Information and Authorization to treat
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
As the Parent and/or Guardian of the named child, 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. 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.*

AgreeDisagree
In case of emergency, I hereby give consent for my child to be transported to the local area hospital:
Photography and Video Release
I, on behalf of my child, grant permission for pictures and/or videos of my child to be takeIn for the sole purpose of literature, advertisements, and events for One Village of New Miami.*

AgreeDisagree
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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Youth Summer Camp Registration Waiting List

Camper Information