Summer Camp Application

Summer Camp Application

Please complete all camper, parent/guardian, medical, permission, and signature fields. Use the provided PDF only as the source for extracted fields; do not preserve its original layout.
Camper Information
Last Name
First Name
Middle Initial
Site
Date of Birth

MonthDayYear
Date
Age
Gender
Ethnic Background

Other
Student Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student ID
Last 4 Digits of SSN
IEP/504 Evaluation
Behavioral/Developmental Concerns
School Attending
Grade
Student Shirt Size
Lunch Status
Total Living in Household
Sibling Information
Family Arrangement

Other
Student Lives With
Parent/Guardian Information
Mother/Guardian Name

First NameMiddle NameLast Name
Mother/Guardian Email
example@example.com
Mother/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mother/Guardian Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Name

First NameMiddle NameLast Name
Father/Guardian Email
example@example.com
Father/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Father/Guardian Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Annual Income
Authorized Pickup

Proper ID is required daily to pick up your child.
Authorized Pickup Contacts
Emergency Contacts
Primary Emergency Contact Name

First NameMiddle NameLast Name
Primary Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Emergency Contact Name

First NameMiddle NameLast Name
Secondary Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Does your child have health insurance?
Medical & Health
Physician Name

First NameLast Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Preference
Allergies
Medications
Medical Diagnosis
Insurance Plan Name
Insurance ID Number
Subscriber Name

First NameLast Name
Parent/Guardian Name (print)

First NameLast Name
Date

MonthDayYear
Date
Signature
Waivers
General Release of Liability

In consideration of being allowed to participate in any way in the After School Program and related events and activities, the undersigned agrees to the following: I acknowledge and fully understand that each participant will be engaging in activities that may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result not only from their actions, inactions or negligence but the action, inaction or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, there may be risks not known to us or not reasonably foreseeable at this time. To my knowledge, my daughter/son is physically fit to engage in the activity in question. I understand that the Duval County School Board, the Kids Hope Alliance, and the selected community-based organization and their employees and agents will exercise reasonable care while my daughter/son is in their custody and care, engaging in activities through the After School Program. I agree to hold the Duval County School Board, the Kids Hope Alliance and the selected community-based organization and its employees and agents harmless from any and all liability, which may arise while exercising their duty of care, relating to my daughter/son for personal injury or illness that may be suffered or any loss of property that may occur to my daughter/son while participating in the KHA Team Up After School Program.
Authorization for Emergency Care

In case of accident or serious illness, and the school/program is unable to reach me, I hereby authorize the school/program to contact the physician indicated on the application and to follow his/her instructions. If it is impossible to contact this physician, the school may make whatever arrangements necessary to provide care and treatment for my child. In case of an accident/serious illness where the immediate treatment of my child is not necessary, but he/she is unable to remain at school, the school/program will contact me or arrange transportation for my child. If the school/program is unable to reach me, I authorize the school/program to contact one of the persons indicated on the enrollment form and ask them to pick up and transport my child home.
Administration of Medication & Medical Release Statement

A policy has been established in Duval County to govern the administration of medicine to students in public schools. The policy states that before medicine can be administered in the school, a statement from the physician concerning the medicine must be on file at the school. Directions taken from the prescription bottle or box will not suffice. Only a written statement from the physician is acceptable. I waive any claims or liability that may arise against any school/program personnel relative to the administration of medication of my child.
Survey Release Statement

I give permission for my child to respond to surveys about participation in the after-school or summer camp program(s) that are conducted by agencies including the Kids' Hope Alliance, affiliated community agencies, and the Florida Institute of Education at the University of North Florida. The parent/guardian is responsible for transporting the youth to and from camp. Elementary-age participants must be picked up by an authorized individual 18+ and must be able to show identification. Students must be picked at the designated camp end time. Failure to comply may result in the camper being removed from the camp.
Photo/Media Release Permission
I acknowledge and understand that publicity activities such as interviews, photos, and videotaping may occur. As a participant in the After School Program and events, I consent and permit my child to be photographed, videotaped, and/or interviewed for publicity activities.
Florida KidCare contact preference
Date

MonthDayYear
Date
Child’s Name

First NameLast Name
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty: