Shan's Academy Camp Compass

Shan's Academy Camp Compass

Please complete this form to register your child for Shan's Academy Camp Compass. Your responses help us ensure a safe and enjoyable camp experience.
Camper Information

Please provide details about the camper.
Camper's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Grade Level
Parent/Guardian Information

Primary contact responsible for the camper.
Parent/Guardian Full Name

First NameLast Name
Relationship to Camper
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Information

Provide additional contact in case of emergency.
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information

Let us know if your child has any medical needs or allergies.
Does the camper have any allergies?
If yes, please list allergies:
Does the camper take any medications?
If yes, please list medications and instructions:
Please list any other medical conditions or special needs:
Photo/Media Release Consent

Permission for your child's photos/videos to be used for camp publications.
Do you consent to your child being photographed or filmed during program activities for promotional purposes?
Waiver and Release of Liability

Please read and agree to the terms to participate in the camp.
I acknowledge and agree to the terms and conditions of Another Chance Care, LLC and Shan's Academy Camp Compass. I release the camp organizers from any liability in case of accident or injury.

Insurance Information

Please provide camper's insurance details.
Camper's Last 4 of SSN
Insurance Company Name
Group Number
Member ID Number
Photo of Insurance Card

Upload a clear photo of the insurance card.
Cancelof

Additional Authorized Pick Up Persons

Please provide information for up to three additional authorized pick up persons.
Authorized Pick Up Person 1 - Full Name

First NameLast Name
Authorized Pick Up Person 1 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick Up Person 1 - Email Address
example@example.com
Authorized Pick Up Person 2 - Full Name

First NameLast Name
Authorized Pick Up Person 2 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick Up Person 2 - Email Address
example@example.com
Authorized Pick Up Person 3 - Full Name

First NameLast Name
Authorized Pick Up Person 3 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick Up Person 3 - Email Address
example@example.com
By signing, you verify that all information provided in this Jotform is correct. Your signature also signifies agreement to all consents and waivers mentioned in this Jotform.
Signature of Parent/Guardian
Should be Empty:

Shan's Academy Camp Compass

Camper Information

Parent/Guardian Information

Emergency Contact Information

Medical Information

Photo/Media Release Consent

Waiver and Release of Liability

Insurance Information

Additional Authorized Pick Up Persons