DHA Summer Camp Registration

Registration Form

Please fill out your details to complete the registration.
I am interested in the following camps for my child(ren):

Child's Information
Full Name

First NameLast Name
Gender
Birthdate

MonthDayYear
Date
Address

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
School and Grade

Parent/Guardian Information
Parent/Guardian 1 Name

First NameLast Name
Relationship to the child
Birthdate

MonthDayYear
Date
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Place of employment, address, and phone number
Put N/A if you're not currently employed.
Parent/Guardian 2 Name

First NameLast Name
Relationship to the child
Birthdate

MonthDayYear
Date
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Place of employment, address, and phone number
Put N/A if you're not currently employed.

Emergency Contact Information
Emergency Contact 1
Emergency Contact 1

First NameLast Name
Relationship to the child
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2
Emergency Contact 2

First NameLast Name
Relationship to the child
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number
Please enter a valid phone number.Format: (000) 000-0000.

Medical Information
Allergies or intolerances to food, medication, or any other substance.
Chronic physical, behavioral or psychological problems, important developmental information, or any special modifications needed:
Type N/A if none.
Does your child take medication or vitamins on a doctors order?
Child's Physician, Office Name, and Phone Number
I give Durham Housing Authority (DHA) Pathways Village permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment, to be transported by ambulance or aid car to an emergency center for treatment, & to obtain immediate medical care and give consent to the hospitalization and performance of necessary diagnostic tests upon, the use of surgery on, and/or the administration of drugs to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement may only cover those situations which are true emergencies and only when he/she cannot be reached. I understand that the provider will take every effort to contact me and/or my designated emergency contacts. I/we will be responsible for payment of medical expenses.
Medical Insurance Provider and Policy #

Waivers
The Durham Housing Authority (DHA) Pathways Village agrees to notify the parent/guardian whenever the child becomes ill, and the parent/guardian will arrange to have the child picked up as soon as possible if requested.
The parent/guardian agrees to inform DHA Pathways Village within 24 hours or next business day after the child or any immediate household members has developed a reportable communicable disease or illnesses that could be considered contagious.
My child has permission to be transported by a Durham Housing Authority (DHA) Pathways Village vehicle and to participate in all program activities and related field trips.
Acknowledgement
I acknowledge that there are certain dangers, risks, illnesses, and personal injuries that can occur when participating in Durham Housing Authority (DHA) Pathways Village programs, events, classes, and/or other activities, which may result in unavoidable accidents or injuries, athletic activities, sports programs/classes, the use of equipment, exercise, or other activities or from me or my minor child(ren)'s physical condition.

I understand Durham Housing Authority (DHA) Pathways Village and its employees, counselors, teachers, trainers, and representatives assume no responsibility for loss, damage, illness or injury to personor property that I or my minor child(ren) may sustain as a result of my or their physical condition or resulting from my or their participation in any activities, programs/classes, events, the use or non-use of any equipment, exercise, and/or any other events sponsored by Durham Housing Authority Pathways Village.

I acknowledge on behalf of myself and my child(ren) that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may result from me and my child(ren)'s participation in any events/classes/activities/programs while at Durham Housing Authority Pathways Village and/or sponsored by Durham Housing Authority Pathways Village.

I acknowledge the Durham Housing Authority Pathways Village often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my child(ren)'s name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation, promotional purposes, or other similar purposes, even if my and/or my child(ren)'s name(s) and/or likeness(es) are an integral part of such photograph, videotape, television program, motion picture, tape recoring, or other similar media.
Release
In consideration of the Durham Housing Authority Pathways Village allowing me and/or my minor child(ren) to attend and/or participate in any programs, events, classes, or other activities at the Durham Housing Authority Pathways Village and/or sponsored by the Durham Housing Authority Pathways Village.

I hereby waive, release and forever discharge the Durham Housing Authority Pathways Village and its employees from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results form the negligence of the Durham Housing Authority Pathways Village and its employees or representativesor from some other cause.
Acceptance
I acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.
Please enter your full name below.
Should be Empty:

Registration Form

Child's Information

Parent/Guardian Information

Emergency Contact Information

Medical Information

Waivers

Acknowledgement

Release

Acceptance