EAST Collective — Summer Camp Intake Form

Camper’s First Name

Camper’s Last Name

Date of Birth

Date

Preferred name or nickname (if different from legal name)

Pronouns (optional)

Camp Week(s) / Which camp(s) are you registered for?

Would you like aftercare for your camper?

Which days does your camper need aftercare?

Leave blank if every day of camp.

What time do you need your camper picked up on aftercare days?

Please confirm your contact information. This is who we'll reach first.

Your Full Name

First NameMiddle NameLast Name

Relationship to Camper

Mobile Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Parent/Guardian 2 Full Name (Optional)

Parent/Guardian 2 Relationship to Camper

Parent/Guardian 2 Mobile Phone

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian 2 Email

example@example.com

Is Parent/Guardian 2 authorized to pick up your child?

Emergency Contact 1 Name

Emergency Contact 1 Relationship to Camper

Emergency Contact 1 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact 2 Name (Optional)

Emergency Contact 2 Relationship to Camper

Emergency Contact 2 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Your child will only be released to adults on this list. If someone new needs to pick up, email us before that morning. You don't need to list yourself or Parent/Guardian 2 here if they're already listed above — the registered parent/guardian is always authorized. List any other adults who are permitted to pick up your child.

Pickup Person 1 Name

First NameLast Name

Pickup Person 1 Relationship to Camper

Pickup Person 1 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Pickup Person 2 Name

First NameLast Name

Pickup Person 2 Relationship to Camper

Pickup Person 2 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Pickup Person 3 Name

First NameLast Name

Pickup Person 3 Relationship to Camper

Pickup Person 3 Phone

Please enter a valid phone number.Format: (000) 000-0000.

Are there any custody orders, legal restrictions, or safety concerns regarding who may pick up or contact your child?

Please describe. EAST may request supporting documentation before enforcing custody or safety restrictions.

Does your child have any food allergies?

Please describe the allergy and any emergency protocol (e.g., EpiPen location, dose, trigger foods to avoid)

Does your child have any environmental or other allergies?

Please describe

Does your child have any medical conditions, physical limitations, or diagnoses staff should know about?

Please describe, including any accommodations that help

Is there anything else you'd like camp staff to know about your child's social, emotional, or behavioral needs?

Does your child have an IEP, 504 plan, sensory needs, communication needs, or other accommodations that help them participate successfully?

Please describe what helps your child participate successfully in a group setting.

Does your child require any medication to be administered during camp hours?

Medication name

Dose

Frequency / timing

Storage requirements

Additional instructions

Physician-signed Allergy/Asthma Action Plan (optional upload)

If your child's doctor has completed a Food Allergy & Anaphylaxis Emergency Care Plan or Asthma Action Plan, you may upload it here so staff have the physician's exact emergency instructions on file. This is optional and in addition to, not instead of, the instructions above.

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for EAST Collective Staff to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize EAST Collective Staff to summon any and all professional emergency personnel to attend, transport, and treat the minor and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur, PROVIDED THAT, prior to such additional care, the EAST Collective Staff shall attempt to contact via phone the legal guardian(s) (or other contact authorized by a legal guardian in writing), and shall only proceed with such additional care if (i) such attempt fails, and (ii) immediate treatment is advised by emergency or medical personnel.. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of EAST Collective Staff in the exercise of their best judgment upon the advice of any such medical or emergency personnel.

EAST staff do not administer over-the-counter or routine medication (Tylenol, ibuprofen, antihistamines, etc.) under any circumstances. If your child needs an over-the-counter medication during camp hours, a parent or guardian must come to the facility and administer it in person. Prescribed emergency medications such as EpiPens and rescue inhalers must be disclosed above and are handled per the Authorization & Consent section.

Can your child manage bathroom use independently?

Please describe what support your child needs

EAST Collective Camps — Story Players & Young Songwriters: EAST Collective operates summer day camps in the arts for children ages 5 and older that are exempt from licensure as a child care agency under Tennessee law (T.C.A. § 71-3-503(b)(9)). These programs have been registered with the Tennessee Department of Human Services and have received written approval to operate.

Story Players Camps (EAST Collective): EAST Collective operates a summer day camp in the arts for children ages 5 and older that is exempt from licensure as a child care agency under Tennessee law (T.C.A. § 71-3-503(b)(9)). This program has been registered with the Tennessee Department of Human Services and has received written approval to operate.

If my child is registered for an EAST Collective camp (Story Players or Young Songwriters): I have been advised and understand that EAST Collective's summer camp programs are not licensed and are not required to be licensed by the State of Tennessee as a child care agency.

Rhythm Kids Camp (Tenn Little Birds): Rhythm Kids is a recreational music and movement camp operated by Tenn Little Birds for children ages 4–8 that is exempt from licensure as a child care agency under Tennessee law (T.C.A. § 71-3-503(b)(8)). This program has been registered with the Tennessee Department of Human Services and has received written approval to operate.

If my child is registered for Rhythm Kids: I have been advised and understand that the Rhythm Kids program, operated by Tenn Little Birds, is not licensed and is not required to be licensed by the State of Tennessee as a child care agency.

Illness Policy: I agree not to send my child to camp if they have a fever of 100.4°F or higher, vomiting, diarrhea, or symptoms of contagious illness within 24 hours prior to camp. I understand EAST staff will contact me for early pickup if my child becomes ill during camp.

I have read and agree to the illness policy.

Lunch, Snacks & Food: Campers must bring their own packed lunch, snacks, and water bottle each day. EAST does not provide meals. Campers may not share food with other campers.

I have read and agree to the food and lunch policy.

Outdoor Activity: Camp may include supervised outdoor time immediately adjacent to the building, weather permitting. Full policy:

I authorize outdoor participation.

Sunscreen assistance: May staff help your child apply parent-provided sunscreen when needed?

Late Pickup & ID: Camp ends at the published time. If I am late, staff will contact me and my emergency contacts. Authorized pickup adults may be asked to show photo ID. Repeated late pickup may affect future enrollment. Full policy: https://www.theeastcollective.com/policies-and-procedures#pickup

I have read and agree to the pickup policy.

Promotional Photo/Video Use: Your camp registration already included a media release. This question lets us flag your preference for camp staff so it's visible day-to-day.

Would you like to opt this camper out of promotional photo/video use?

E-Signature

Printed Name

Date

When you registered for camp through EAST Collective, you already agreed to our Assumption of Risk & Waiver of Liability, Media Release (Photo/Video), and Cancellation Policies. You do not need to re-sign those here. If you have any questions about those agreements, or if you would like to make a change — including opting out of photo and video use — please note it below and we will follow up before camp begins.

Questions or changes to my registration agreements (optional)

Example: 'Please opt my child out of photos and video,' or 'I have a question about the cancellation policy.'

Additional Emergency Contacts (optional)

EAST / TLB Summer Camp Intake Form

About Your Camper

Parent / Primary Guardian

Emergency Contacts

Authorized Pickup

Health & Medical Information

Medication

Bathroom Independence

Policy Acknowledgments

Health & Participation Policies

Signature