CRS BW 2025

Name

First NameLast Name
My child will particpate in (please make all that apply):

Swimming at Hickory Hill Community CenterBowling at Cordova Bowling CenterJumping World
Gender*
Age*
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Hearing Status
T-Shirt Size
Parent or Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Work Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Email*
example@example.com
How did you learn about us?
Emergency Contact*

First NameLast Name
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Alternate Emergency Contact

First NameLast Name
Relationship to camper:
Day Phone

Area CodePhone Number
Night Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Medical Information
Please list all known medical conditions.*
asthma, allergies, etc.
Is camper on medication?*
Is camper ALLERGIC to any medication?*
If yes, what med(s) is child on:
medication camper is on
If yes, what med(s) is your child allergic to:
medication camper is allergic to
Please note that all medications must be listed. Please understand that campers cannot keep their medications. A staff member will collect and distribute daily medications.
Is participant currently under the care of a doctor? If so, please include doctor's name & phone number.

Persons Permitted to Pick Up Camper other than Parent|Guardian
Name

First NameLast Name
Relationship
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Name

First NameLast Name
Relationship
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Any additional information we should know?

Releases & Consents
Media Release

I give my permission for BridgesDHH to allow photographs or interview statements of my child to be used as part of any publicity coverage that may occur including newsletters, public relations materials, or coverage by area media in regard to BridgesDHH youth center programming.
yesno
Please Sign & Date*

Clear
Activity & Travel Consent

During Camp Rise & Sign, the camper will have the opportunity to participate in various activities including: arts and crafts, sports and games, educational seminars, and outdoor activities. As a parent/guardian, I understand the nature of these activities and give permission for my child to participate.

I also give consent for BridgesDHH to transport my child to and from activities. BridgesDHH is not liable for any harm to them or damage to personal property.
Please Sign & Date*

Clear
Swimming Consent

My child will have an opportunity to participate in group swimming activities. As a parent/guardian, I understand the nature and risks of this activity and give permission for my child to participate.
Please Sign & Date*

Clear
My child's swimming ability:
We ask that you complete a form for each child, but please list the name(s) of other campers here for reference:
Should be Empty:

Medical Information

Persons Permitted to Pick Up Camper other than Parent|Guardian

Releases & Consents