Teen Life: Building Relationship Skills Camp - Registration and Consent Form

Teen Life: Building Relationship Skills Camp - Registration and Consent Form

Dallas College Summer Camp Series
Camp Location
Name of Camper

First NameLast Name
Parent/Guardian Email
example@example.com
Camper's Date of birth

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone #
Please enter a valid phone number.Format: (000) 000-0000.
T-shirt Size
Medical Information
Please specify the type of special accommodations needed, including dietary needs, if applicable.
List any current medical conditions, allergies, medications, if applicable.
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Consent and Authorization
I, the undersigned, hereby declare and affirm that:

I am the parent/legal guardian of the youth named above (hereinafter referred to as "Camper"), who is under my care and responsibility.

I hereby consent and give authority to the participation of my Child in the scheduled youth activities of the Camp, and all other activities which is supervised and customarily associated with its youth group.

I hereby declare and affirm that my Child is physically fit to take part in the Camp's activities and my Child has no known illness or adverse medical condition that would render him/her unfit to participate therein, other than the information specified in the medical information above.

I shall immediately advise the organizers in writing, should I discover any illness, adverse medical condition, or any other physical defect that would render my Child unfit to participate in the activities of the Camp.

I shall notify the organizers immediately in case I revoke my consent to the Camp for this event.

Rebecca’s House Foundation

Teen Life: Building Relationship Skills

Parent/Guardian Consent

A parent/guardian’s consent is required for your child to participate in this program. This program equips teens with the proper skills to develop healthy relationships in their present and future life. These relationships include: understanding healthy relationships, emotional regulation, conflict resolutions, dating, relationship red flags and communication skills. Your child will receive practical strategies that develop self-control, positive identity, significance, and social interaction skills.

Your child will also have the opportunity to participate in an anonymous survey about what teens think about relationships, teen pregnancy, and their ability to apply the skills they learn in the program. Your child WILL Not write their name on the survey. The information will be used to help develop better prevention programs. Taking this survey is their choice. All answers will be kept private and any question your child does not feel like answering can be left blank. As a parent, you have the right to remove your child from any part of this program.
Please check each statement below you agree with:
Name of Parent/Guardian

First NameLast Name
Contact Number
Format: (000) 000-0000.
Signature of Parent/Guardian
A link will be sent to your email with the $20 registration payment fee options to finalize your registration.
Should be Empty:

Teen Life: Building Relationship Skills Camp - Registration and Consent Form

Medical Information

Consent and Authorization

A link will be sent to your email with the $20 registration payment fee options to finalize your registration.