C.A.M.P. ME Registration Form

Camper's Name

First NameLast Name

Preferred Name/Nickname

Birth Date

MonthDayYear

Grade

MaleFemaleNon-Binary

She, HerHe, HimThey, Them

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Days Attending: Full Day Session

Days Attending: Alternative Recreations Sessions

Appointment

Does the camper identify as neurodivergent? (e.g., ADHD, Autism, Dyslexia, etc.) If yes, please describe.

If yes, how would you describe their neurodivergence? (optional)

Does the camper have any specific sensory sensitivities? (Lights, sounds, textures, etc)

Are there any accommodations or support needs? (noise cancelling headphones, alternative communication methods, scheduled breaks)

Does the camper require any assistive devices or technology? (AAC device, fidgets, weighted blankets, etc) If yes, please describe.

Campers preferred ways to communicate? (verbal, non-verbal, written, sign language, etc) If yes, please describe.

What helps the camper feel safe and comfortable in new environments? Please describe.

Are there any social preferences we should know of? (Group VS Individual activities, structured VS unstructured interactions) Please describe.

Does the camper have any preferred strategies for emotional regulation? (e.g breathing exercise, movement exercise, or quiet spaces) If yes, please describe.

Does the camper have any triggers or known situations that may cause distress? If yes, please describe.

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Are there any medication(s) the camper takes daily? If yes, please list medication and frequency/time of day med is taken?

Does the camper have any specific medical conditions we should be aware of? If yes, please describe.

What activities does the camper enjoy? Please describe.

Does the camper have any activities they prefer to avoid? If yes, please describe.

Does the camper have any hobbies or special interests that bring them joy? If yes, please describe.

Is there any other details we should know of to help to create a positive and enjoyable camp experience? If yes, please describe.

Informed Consent and Acknowledgement

I hereby give my permission for my child’s participation in any and all activities prepared by Smart Choice Solutions, LLC during the selected camp. In exchange for the acceptance of said child’s candidacy by Smart Choice Solutions LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Smart Choice Solutions LLC 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 Smart Choice Solutions LLC including all staff 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 physical activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

By providing my consent, I hereby grant permission for my child's likeness and image to be captured, recorded, and utilized in various forms. This may include photographs, videos, or any other visual representations of my child. The intended use of these materials is to document and showcase my child's experiences, activities, and achievements within the context of educational, extracurricular, or promotional purposes.

I understand that the collected materials may be utilized by authorized personnel.

Social Media Platforms: With my prior consent, the materials may be shared on authorized camp and agency social media platforms to provide real-time updates and engage with the broader community.
I acknowledge that the captured materials may be stored and archived by Smart Choice Solutions for record-keeping purposes. I trust that appropriate measures will be taken to protect my child's privacy and ensure that the materials are used solely for authorized purposes.

By providing this consent, I authorize Smart Choice Solutions to use my child's likeness and image in a respectful and responsible manner, adhering to ethical guidelines and applicable laws. I understand that I have the right to withdraw my consent at any time by submitting a written request to Smart Choice Solutions.

Upload Immunization Records

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 camper. 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 Smart Choice Solutions LLC and its affiliates including directors, counselors, and staff 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.

Signature

Date

Dates Attending (Alternative Recreational Session):

Date

Hour MinutesAM/PM Option

Time

Hour Minutes

AM/PM Option

Until

until

Hour Minutes

AM/PM Option

Summer Camp Registration

Camper's Information

Photo Release