Coastal Kids Learning Center: Summer Camp Registration Form

I want to register for:
Camper's Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Rising Grade
Address

Street Address

Street Address Line 2

CityState / Province

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

First NameLast Name
Relation
Parent/Guardian 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Place of Work
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Name

First NameLast Name
Relation
Parent/Guardian 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Place of Work
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent Agreements
I do hereby and forever discharge the participants, facilitators, and administrators of Coastal Kids Learning Center, LLC of any and all actions, claims, and demands for or by reason of any damage, loss, or injury which hereafter may be sustained.

I understand that the registration fee is non-refundable.

I agree to pay the one time registration fee of $40 plus $175 for each week of camp I select. The $175 fee is due no later than the chosen week(s) of camp.

Signature*
Date: blank*

Emergency Contact (other than Parents/Guardians)
Emergency Contact Name (other than Parents/Guardians)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Please share any information regarding your child’s health issues, any delays in: hearing, speech, fine or gross motor skills, or behavioral/emotional development.
Does your child have any known allergies? (Yes/no) if yes, please list and explain reaction.
Daily Medications and Dosage:
Any other information on your child you would like to share:

I hereby give permission for my child, First Name* Last Name* , to be given emergency treatment (first aid and CPR) by a qualified staff member at Coastal Kids Learning Center, LLC.

In an emergency situation, I also give my permission for my child to be transported by ambulance to an emergency center for treatment, and give my permission to Coastal Kids Learning Center, LLC to provide a copy of this Consent Form to Emergency Medical Service (EMS) Personnel.

In the event of an emergecy situation, and once the child is under EMS care, I understand that Coastal Kids Learning Center will release the care of child to the EMS personnel for medical care.

In the case of an emergency, and if emergency transportation is needed,
I, First Name* Last Name* , agree to pay emergency transportation costs and I accept liability for all expenses incurred.
Child's Physician

First NameLast Name
Physician's Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Tetanus (or DPT)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Medications/Dosage
Allergies & Reaction
Medical Insurance
Policy Number
Policy Holder
Parent/Guardian 1 Name

First NameLast Name
Parent/Guardian 1 Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Signature
Date Parent/Guardian 1 Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian 2 Signature
Date Parent/Guardian 2 Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

I give permission for Coastal Kids Learning Center, LLC to use images or videos of my child, First NameLast Name in any Coastal Kids Learning Center publication or promotional materials. I understand that these images or videos will be used for the sole purpose of promoting Coastal Kids Learning Center, and that no child’s name will be included on any materials.
Name of Parent or Guardian

First NameLast Name
Signature of Parent or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I do not give permission for the use of images or videos of my child, First Name Last Name , to be used by Coastal Kids Learning Center.
Name of Parent or Guardian

First NameLast Name
Signature of Parent or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Camper's Information

Parent/Guardian Information

Parent Agreements

Emergency Contact (other than Parents/Guardians)

Medical Information