Kids Fall Day Camp Registration

Name of Student #2 (if applicable)

First NameLast Name
Date of birth of Student #2 (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
List all food allergies Student #2 has (type N/A):
Are you Registering another Student?

Name of Student #3

First NameLast Name
Date of birth of Student #3

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
List all food allergies Student #3 has (type N/A):

Contact Information
Name of Emergency Contact

First NameLast Name
Relationship to Camper
Phone Number of Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Additional Pick-up Person

First NameLast Name
Additional Pick-up Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If someone other than the parent or guardian or emergency contacts listed here is picking your child up, you MUST LIST THE INDIVIDUAL with FULL NAME and with PHONE NUMBER. The individual who picks up your child(ren), MUST SHOW identification (driver's license, state ID, passport).
Photo Release Consent
I hereby authorize Japanese American Service Committee ("JASC") and its representatives to use, print, publish, or display a picture and/or use my name for public relations or other purposes to benefit the JASC and its program. I have read and understand this consent form.
Authorized Representative's Name

First NameLast Name
Authorized Representative's relationship to child being registered
Relationship

JASC's Fall Kids Day Camp Registration Form