Minicamp Registration

Youth Registration for CISV Jacksonville Minicamp - Apr 2022

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 Jacksonville Minicamp - Apr 2022

Date: Friday night, April 29 to Sunday afternoon May 21, 2022

Event Address: Camp St. John, 235 Marywood Drive St. Johns, FL 32259 (off SR13, 3 miles south of Racetrack Rd.)

Onsite Lead Chaperones: Joanna Simpson
Full Name of Youth Participant *

First Name Last Name
Gender Identity *

Male Female Other
Age of Participant at Camp Start *
Age in Years
Date of Birth of Youth Participant *

Month Day Year
Date
Address of Youth Participant

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Youth Participant

Area Code Phone Number
E-mail of Youth Participant
Parent/Guardian #1 Name *

First Name Last Name
Parent/Guardian #1 Phone Number *

Area Code #1
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #2 Name

First Name Last Name
Parent/Guardian #2 Phone

Area Code Phone Number
Parent/Guardian #2 Email
example@example.com
Name of Alternate Emergency Contact

First Name Last Name
Phone of Alternate Emergency Contact

Area Code Phone Number
Phone of Person Picking Up Youth Participant

Area Code Phone Number

Acknowledgement: All drivers who drive campers to or from minicamp must be at least 23 years old unless they are in the same family (legal requirement) or are driviing themselves. *

Yes
I give my consent for my child age 16+ to drive themselves

Yes No Not 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.
Is the youth participant fully-vaccinated against Covid-19?

Yes No
Upload Covid-19 vaccine card

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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 2/18/2022 To 2/21/2022. *

YES I AUTHORIZE

Youth Registration for CISV Jacksonville Minicamp - Apr 2022

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

Use of the MyCISV Website

National Code of Conduct for Junior Branch USA

Legal Release & Responsibility to Pay for Damage