Gateway Wellness Center
Follow Me and Lead Youth Leadership Academy
Camper Information
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Camper's Age
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there anything you would like us to know to better support your child’s needs, learning style, or behavior while participating in this program?
Would you prefer to discuss this with a summer camp staff member?
Yes
Emergency Contact Details
Name of Emergency Contact
*
Must be available during camp hours
Relationship to Camper
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Permission to Pick Up
The individuals below have permission to pick-up my child from Summer Camp.
Name
Relationship to Camper
Name
Relationship to Camper
Name
Relationship to Camper
Consent to Walk
Please choose one of the following options regarding consent to walk.
*
I give my child consent to walk home from Summer Camp.
I DO NOT give my child consent to walk home from Summer Camp.
Dietary/medical Information
Camper does not have any allergies/dietary restrictions.
If camper has any allergies or dietary restrictions, please list below.
Camper does not have any medical limitations/restrictions.
Specify any conditions/medical limitations that may affect camper during camp and require special care.
Photo Release Agreement
Type a question
*
I hereby give Gateway Wellness Center permission to use images of my child, captured during Follow Me and Lead Youth Leadership Academy through video, photo, and digital camera, to be used soley for the purposes of Follow Me and Lead Youth Leadership Academy promotional material and publications.
I DO NOT grant Gateway Wellness Center permission to use images of my child captures during Follow Me and Lead Youth Leadership Academy
Parental Consent/ Agreement
By signing below, I hereby verify that all information on this document is true and accurate information regarding my child.
Guardian Name
First Name
Last Name
If the camp reaches capacity, would you like to be placed on the waiting list?
*
Yes, add us to the waiting list
No, do not add us to the waiting list
Submit
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