SPRING 2026 - CAMP NICK REGISTRATION

Parent/Guardian Information

Also referred to as Client Representative for minors
Parent/Guardian Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*
Format: (000) 000-0000.
YesNo
Home or Work Phone Number
Format: (000) 000-0000.
YesNo
Best email address to reach you*
example@example.com
I allow NFCC to contact me via email regarding camp updates and billing.*
I understand that there are risks associated with email communication and confidentiality
Are there any custody agreements related to this minor?
If yes, please provide our office with a copy of custody documents at least 2 days before camp begins.

Emergency Contact

NFCC will contact this person if there is an emergency situation during camp and we are not able to reach the parent/guardian listed above.
Emergency Contact's Name*

First NameLast Name
Relationship to Client*
Phone Number*
Format: (000) 000-0000.

Medical/Insurance Information
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed and/or taking any medications? If yes, please describe.
Name of Primary Physician*
Physician Phone*
Format: (000) 000-0000.
Health Insurance Provider (if none, leave blank)
Policy Holder Name
Member/Group Number
Pre-Authorization Phone
Format: (000) 000-0000.
Medical Treatment

In the event I cannot be reached to make arrangements for emergency medical attention, I authorize St. Luke's staff members or authorized counselors to obtain emergency medical treatment in case of illness or injury to the participant named above.
Texas Children's HospitalOther

Informed Consent and Permissions
Notice of Privacy Practices & Informed Consent for Treatment*
I grant permission for the Nick Finnegan Counseling Center, its staff, and authorized volunteers, to take photographs and/or video of my child while participating in programs and/or events, and to publish the same (name withheld) in print, electronic and/or broadcast media, for promotional and informational purposes..I do NOT grant permission.
Authorization for Treatment

I agree that I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me.
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

CAMP NICK REGISTRATION