SRMC Youth Registration

Youth Registration for CISV Southern Regional Minicamp

Please fill in the form below.
Intended use: This form shall be used for all activities occurring in the United States (mini camps, Annual Meeting & Conference/CISV In Motion, National Youth Meeting, National Leadership Training, etc.), by youth under the age of 18.
This form is to be completed by the parent or legal guardian of the participant. Completion and signing of this form is a condition of participation in the CISV activity named below.

Event: CISV Southern Regional Minicamp

Date: Labor Day Weekend from Friday night to Monday morning

Event Address: Camp Suwanee 11057 Dowling Park Drive
Dowling Park, Florida 32060

Onsite Chaperone: Kerry McClure or Shannon Arola
Full Name of Youth Participant*

First NameLast Name
Gender Identity*

MaleFemale
Age of youth at minicamp
Date of Birth of Youth Participant*

MonthDayYear
Date
Address of Youth Participant

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Youth Participant

Area CodePhone Number
E-mail of Youth Participant
Parent #1 Name*

First NameLast Name
Parent #1 Email
example@example.com
Parent #1 Phone Number*

Area Code#1
Parent #2 Name

First NameLast Name
Parent #2 Email
example@example.com
Parent #2 Phone

Area CodePhone Number
Name of Alternate Emergency Contact

First NameLast Name
Phone of Alternate Emergency Contact

Area CodePhone Number
Which CISV Chapter*
T-shirt size of Youth Participant*
Name of Adult Chaperone (for chapters other than Jacksonville). If you do not know yet, leave this blank and come back later to complete the info or email us at cisvjax@gmail.com.

First NameLast Name
Phone of Person Driving Youth Participant (for chapters other than Jacksonville)

Area CodePhone Number

Carpooling Availability

This section is for Jacksonville-based participants only.
Are you available to drive a group from Jax to minicamp on Fri night? (pickup in Jax around 5:30pm) (for Jax participants only) All drivers must be at least 23 years old.*

YesNo
Are you available to drive a group from minicamp to Jax on Labor Day in the morning? (for Jax participants only). All drivers must be at least 23 years old.*

YesNo
Number of People than your car could hold (excluding driver) (for Jax participants only)
I give my consent for my child age 16+ to drive themselves

YesNoNot applicable
Health and Dietary Restrictions
Please describe any dietary restrictions for your child - vegan, gluten-free, allergies, etc. Write "None" if your child has no dietary restrictions.
Please describe any health issues or restrictions that might affect your child's participation. Write "None" if your child has no health restrictions.
Please describe any medications that your child will be taking during the event. Write "None" if your child has no medication restrictions.
Please describe any allergies. Write "None" if your child has no allergies.

Authorization for Participant to Travel With an Adult Chaperone & Appointment of Temporary Guardian
I give permission for my child (named above) to travel to and from the CISV activity with the Adult Chaperone(s) named above. I hereby appoint the Adult Chaperone(s) as Temporary Guardian(s) of my child for the purpose of consenting to medical treatment and providing prescribed medication. If the Adult Chaperone(s) is not available, and prompt medical attention is needed, I also appoint CISV personnel (activity staff or host family) from the host Chapter/CISV USA to consent to medical treatment on behalf of my child. This appointment is valid for the period: From 8/30/2019 To 9/2/2019.

YES I AUTHORIZE

Youth Registration for CISV Southern Regional Minicamp

Carpooling Availability

Health and Dietary Restrictions

Authorization for Participant to Travel With an Adult Chaperone & Appointment of Temporary Guardian

Phone Policy

Medical Insurance & Financial Responsibility for Medical Treatment

Permission to Use Photographs, Art or Written Work

Permission to Swim

Use of the MyCISV Website

National Code of Conduct for Junior Branch USA

Legal Release & Responsibility to Pay for Damage