AVIDITY Adventurer's Registration

Adventure Program Registration

Summer Adventure
Week 1

June 24th-28th
Adventurer Information
Last Name: *
First Name: *
Middle Initial: *
Gender: *

Male Female
Street Address: *
City: *
State: *
Zip: *
Birth Date: *

Month Day Year
Current grade: *
(2018-2019 academic year)
Parent or Legal Guardian Information
Parent/Legal Guardian Name: *
(First and Last)
Relation to child: *
Daytime/Work Phone *

Area Code Phone Number
Cell Phone

Area Code Phone Number
Parent /Legal Guardian 2: *
Relation to child: *
Relation 2: *
Daytime/Work Phone 2: *

Area Code Phone Number
Cell Phone 2:

Area Code Phone Number
Emergency Contact Info
Emergency Contact Name (if parent or guardian is not avaliable) *
Relation to child: *
Emergency Number *

Area Code Phone Number
Email Confirmation

We value your privacy. Email addresses will only be used for communications related to the Adventure Program and will never be shared with or distributed to a third party.
Parent's Email: (confirmation will be sent by email, if left blank it will be mailed)
Be certain to enter your email address correctly on the registration form to receive confirmation via email within 2 weeks
Youth's Email:
Other Information
How did you hear about our Adventure Program?
First Time participant? *

Yes No
Health Information
Does your child have allergies of medical concern? *

Yes No
If Yes please explain:
Are immunizations up to date?

Yes No
Any activity the youth should be restricted from?
(i.e., swimming, biking, or other physical activities)
Youth Photo Release
I agree that photos of my child can be taken and used for social media purposes

Yes No
With your consent, photos taken of the youth while taking part in Adventure Program activities will be used solely for the purpose of promoting the Adventure Program on Avidity's website (www.avidity.org) and its affiliated social media accounts.
Terms & Conditions

By typing your name and submitting this form, you consent and agree to the following:
You are the parent or legal guardian of the above named camper, and you are over the age of 18.

In the unfortunate and unlikely event of harm or injury, you release Partnership for Community Health, Inc. d/b/a Avidity from any and all liability, and give consent for medical treatment to be administered to the above-named camper by authorized personnel. The camp carries secondary insurance, and Avidity is committed to safeguarding your child’s safety and wellbeing.

You understand that the above named camper will only be released to the names listed above (an update may be done at registration).

My child has my permission to attend the Adventure Program Spring Break Camp and participate in all activities.
Electronic signature: *
First Name & Last Name
Registration Fee *
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Summer Adventure Registration $ 320.00

Total $ 0.00
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Adventure Program Registration

Week 1

Adventurer Information

Parent or Legal Guardian Information

Emergency Contact Info

Email Confirmation

Other Information

Health Information

Youth Photo Release

Terms & Conditions