Summer Camp Detailed Registration Form

Revolutionary Thinkers Summer Camp Registration
Camper Information
Camper's Name

First NameLast Name
Age
Grade
Name of School (if applicable)
School District
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
- The parents/guardian listed below will be the authorized person to pick-up the child after the camp.
- The parents/guardian listed below will also be the primary emergency contact person.
Name

First NameLast Name
Relationship
E-mail
example@example.com
Cell Number
Phone Number
Emergency Information
Alternate Emergency Contact's Name

First NameLast Name
Relationship
Cell Number
Phone Number
Medical Information
Does the camper have any allergies? If yes, please list them below.
Does the camper have any previous injuries? If yes, please explain them below.
Does the camper have any current medical conditions? If yes, please list them below.
Does the camper take any medication? If yes, please list them below and explain its purpose. Please note any medications that must be dispensed during camp hours.
Please explain any other important information that the York County History Center staff need to be aware of.
Photo Authorization
- I, the parent/guardian of this camper give permission for my child's photo to be taken and possibly used for marketing and promotional materials for the York County History Center.
Authorization
- I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached.
- I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
- I released the organizers, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment.
- I confirm that all information given in this form is true, complete, and accurate.
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

Clear
Should be Empty:

Revolutionary Thinkers Summer Camp Registration

Camper Information